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(CRL) Administrative Manual (group) PRO-0456 8/28/03 Application (group 2-50) Employee APL-0547 9/05 Application (group 51+) Employee APL-0548 9/05 Application (group) Employer Participation Request/Agreement PRQ-GPT2 3/05 Application Advantage Products (individual) APL=0549 2/05 Authorization - Release Medical Information AEF-0583 12/04 Change Request Form (group) SEF-0092 10/03 Checklist - HSA (group) Checklist - Partnership Plan (group) Checklist - PMOP (group) Checklist - Submitted New Business (individual) SEF-0138 12/05 Checklist (group) SEF-0031 4/05 Claim Form Dental CEF-GRP32 10/97 Claim Form Prescription - Express Scripts COBRA Election Form AEF-Cobra2 11/05 COBRA Notice AEF-Cobra4 10/04 Dental Smile Protector Employer Application (group) APC-0069 5/01 Dental Smile Protector Employee Application (group) APC-0067 4/01 Dental Smile Protector Brochure (group) PRB-0369 4/01 Eagle Consumer Association Application/Brochure PRO-0033 10/03 EFT Form (individual) AEF-0303 3/03 Eligible Individual Application APL-GRP48B 7/99 Eligible Individual Brochure PRB-0158 6/03 Elite Advantage Application APL-0549 2/05 Elite Advantage Brochure PRB-0496 1/06 HIPAA & Employers AEF-0590 3/04 HSA - ABCs of your Heatlh Savings Account PRO-0626 2/05 HSA - Application My Health Savings Bank APL-0557 9/04 HSA Enhancement 2006 (grp-indiv) PRB-0350 12/05 HSA Plus Certificate Booklet CEB-0820 4/05 HSAdvantage Brochure (group) PRB-0388 5/04 HSAdvantage Plus Application (individual) APL-0549 2/05 HSAdvantage Plus Brochure (individual) PRB-0485 9/05 LabOne PRO-0354 3/01 Licensing Agent Contract/Application Form APL-0104 1/06 Licensing Agent Direct Deposit Form SEF-0128 5/05 Non-Profit Organization Questionnaire AEF-0191 6/96 Ohio Mandate Insert PRB-0085 6/05 Optional Employee Deductible AEF-F046 9/94 Partnership Western Reserve Administrative Service Agreement AEF-W017 Partnership Western Reserve Administrative Service Monthly Cap AEF-W015 4/03 Partnership Brochure PRB-0165 2/02 Partnership Brochure Supplement PRB-0472 5/04 Partnership Enhancements 2006 (group) PRB-0350 12/05 Payroll Deduction Authorization AEF-T068 3/05 PMOP Brochure PRB-463 4/03 PMOP Enhancements 2006 (group) PRB-0350 12/05 Prescription Claim Form (see above under CLAIM FORM) Producer Guide (small group) MAN-0029 5/02 Producer Guide (individual) HSA MAN-0043 12/04 Producer Guide (individual) MAN-0030 12/03 Product Grid Advantage Plans (MIS form) 2/06 Select Advantage Application APL-0549 2/05 Select Advantage Brochure PRB-0486 8/05 Short Term Medical Application PRO-0541 8/05 Short Term Ohio Mandates Insert PRI-0161OH 8/05 Term - Employer Instructions AEF-GPT1-4 9/99 Term - Continuation/Conversion AEF-GPT102 1/04 Term - Notice of Conversion AEF-GPT36 10/93 Underwriting Guidelines (individual) MAN-0044 6/05 Verification Guidelines PRO-0552 4/04 Vision - VSP PRO-0535 6/04

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