Pd Eh

*QLWHG +RPH /LIH,QVXUDQFH &RPSDQ\

* (DVW *W Ɣ * * %R Ɣ,QGLDQDSROLV,1 Ɣ H$SS $XWKRUL]DWLRQV DQG )&5$ 0 QF 1RWLFH

3ULQWHG 1DPH RI 3URSRVHG,QVXUHG 3URSRVHG,QVXUHG 'DWH RI %LUWK

6(&7,21 XWKRUL]DWLRQ

, KHUHE\ DXWKRUL]H DQ\ OLFHQVHG SK\VLFLDQ PHGLFDO SUDFWLWLRQHU KRVSLWDO FOLQLF SKDUPDF\ EHQHILW PDQDJHU RU RWKHU PHGLFDO RU PHGLFDOO\ UHODWHG IDFLOLW\ HOHFWURQLF KHDOWK UHFRUG SURYLGHU PHGLFDO LQIRUPDWLRQ UHWULHYDO VHUYLFH LQVXUDQFH FRPSDQ\ 0 QF 0,% RU RWKHU RUJDQL]DWLRQ LQVWLWXWLRQ RU SHUVRQ WKDW KDV DQ\ UHFRUGV RU NQRZOHGJH RI PH RU P\ GHSHQGHQWV LI WKH\ DUH WR EH LQVXUHG RU RXU KHDOWK WR JLYH WKH 8QLWHG +RPH /LIH,QVXUDQFH &RPSDQ\

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

, XQGHUVWDQG WKDW 8+/ PD\ UHTXLUH WKDW, VXEPLW WR DQ +,9 +7/ 9,,, 6FUHHQ DXWKRUL]H WKDW WHVW IRU XQGHUZULWLQJ SXUSRVHV 3ULRU WR WHVWLQJ PXVW EH SURYLGHG DQG VLJQ D VHSDUDWH QRWLFH DQG FRQVHQW IRUP LI UHTXLUHG E\ WKH VWDWH ZKHUH WKH SROLF\ LV GHOLYHUHG RU LVVXHG IRU GHOLYHU\

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

7KLV DXWKRUL]DWLRQ FRPSOLHV ZLWK WKH +,3$$ 3ULYDF\ 5XOH

, DXWKRUL]H DQ\ KHDOWK SODQ SK\VLFLDQ KHDOWK FDUH SURIHVVLRQDO KRVSLWDO FOLQLF ODERUDWRU\ SKDUPDF\ RU SKDUPDF\ EHQHILW PDQDJHU PHGLFDO IDFLOLW\ RU RWKHU KHDOWK FDUH SURYLGHU WKDW KDV SURYLGHG SD\PHQW WUHDWPHQW RU VHUYLFHV WR PH RU RQ P\ EHKDOI ZLWKLQ WKH SDVW HDUV 0\ 3URYLGHUV WR GLVFORVH P\ HQWLUH PHGLFDO UHFRUG SUHVFULSWLRQ KLVWRU\ PHGLFDWLRQV SUHVFULEHG DQG DQ\ RWKHU SURWHFWHG KHDOWK LQIRUPDWLRQ FRQFHUQLQJ PH WR 8QLWHG +RPH /LIH,QVXUDQFH

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

%\ P\ VLJQDWXUH EHORZ DFNQRZOHGJH WKDW DQ\ DJUHHPHQWV, KDYH PDGH WR UHVWULFW P\ SURWHFWHG KHDOWK LQIRUPDWLRQ GR QRW DSSO\ WR WKLV DXWKRUL]DWLRQ DQG, LQVWUXFW DQ\ SK\VLFLDQ KHDOWK FDUH SURIHVVLRQDO KRVSLWDO FOLQLF PHGLFDO IDFLOLW\ RU RWKHU KHDOWK FDUH SURYLGHU WR UHOHDVH DQG GLVFORVH P\ HQWLUH PHGLFDO UHFRUG ZLWKRXW UHVWULFWLRQ

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

, XQGHUVWDQG WKDW, KDYH WKH ULJKW WR UHYRNH WKLV DXWKRUL]DWLRQ LQ ZULWLQJ DW DQ\ WLPH E\ SURYLGLQJ ZULWWHQ UHTXHVW IRU UHYRFDWLRQ WR 8QLWHG +RPH /LIH,QVXUDQFH

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

, XQGHUVWDQG WKDW 0\ 3URYLGHUV PD\ QRW UHIXVH WR SURYLGH WUHDWPHQW RU SD\PHQW IRU KHDOWK FDUH VHUYLFHV LI, UHIXVH WR VLJQ WKLV DXWKRUL]DWLRQ IXUWKHU XQGHUVWDQG WKDW LI, UHIXVH WR VLJQ WKLV DXWKRUL]DWLRQ WR UHOHDVH P\ FRPSOHWH PHGLFDO UHFRUG 8+/ PD\ QRW EH DEOH WR SURFHVV P\ DSSOLFDWLRQ RU LI FRYHUDJH KDV EHHQ LVVXHG PD\ QRW EH DEOH WR PDNH DQ\ EHQHILW SD\PHQWV RU P\ DXWKRUL]HG UHSUHVHQWDWLYH KDYH D ULJKW WR UHFHLYH D FRS\ RI WKLV DXWKRUL]DWLRQ

6(&7,21 6LJQDWXUHV

6LJQDWXUH DSSOLHV WR 6HFWLRQV DQG 5HYLHZ EHIRUH VLJQLQJ

'DWHG DW WKLV GD\ RI

6LJQDWXUH RI 3URSRVHG,QVXUHG RU SHUVRQDO UHSUHVHQWDWLYH

'HVFULSWLRQ RI SHUVRQDO UHSUHVHQWDWLYH V DXWKRULW\ WR DFW

Aretha HARRIS 07/13/1967

3/($6 7 1 9( 72 $33 17

)$,5 &5(',7 5(3257,1 7 0 1 127

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

Contact this candidate