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<br />All ExcelllJs Compan'l <br /> <br />Simpl city. <br /> <br />Administrative Offices <br />165 ('ourt St. <br />Rochester, NY 14647 <br />Fax: 585-238.3642 <br /> <br />rvlErAmerica <br /> <br />MtdAnMriQ Inlurance tlm(lanVj...(l"If~ onto _it ", <br />MIdAmericalnsura"" Company.t lew 'foR _t t".. ji;,(",,'f' II- <br /> <br /> <br />(1 " <br />; . J. I <br /> <br />Direct Bill to Employee/Member <br />BiIIsentdirectlytoemployeesmailingaddress.______.._.____ __ ~__ ___' . ________ -.-----.---- - <br />o 100% Employer Paid - Billed to Employer (select one) 0 Monthly 0 Quarterly 0 Semi-Ann 0 Annual <br />___ ..5!!.r more ~plications (out of the 10 minimum) areJf!9!!!!..~fro!'!_'!cti'!.~IJt-Cl.t~o!1_e.rr1plp.YI!e.!?tQ cre.ate one.. bill anQ send to..t!!!L~rr1p.loy.er. <br />o Payroll Deduction (Monthly Only) <br />Re uires submission of Pa roll Questionnaire and 10 or more a Iications from activel -at-work em 10 ees for a roll deduction. <br /> <br />Agent of Record Name <br />Mailing Address <br />City, State, Zip <br />--. --_.~.- _ -_._.__.-._-- <br />Producer Writing No. <br />I' -- ------.-~... ........ -.--.. <br /> <br /> <br />l~~p~~di~;;~ency <br /> <br />I Rhonda Peterson <br />~-.._.__.._--- - ~- <br />4510 13th Ave S <br />Fargo, NO 581210001 <br />License # ADEQ3 <br />rhonda.peterson@noridian.com <br />-.. --.--.' -.. .--...- <br />Noridian Insurance Services <br /> <br /> <br /> <br />~ <br /> <br />Date <br /> <br />'-' <br /> <br />sencfCom -reted formfO: -- 'MedAmericaSales" De t. -- <br />. . - . <br /> <br />i Or FaiCom-Teted-Form to: <br /> <br />.---~85-238-3~- <br /> <br /> <br />Approval Signature: <br />G.rq!:lQl':Iuml;l~..r:"=-=-==== r===---= <br />..1;!<~~~iI{i!L ____________nLYEl~___ <br />* Group exclusivity is at the discretion of MedAmerica. <br /> <br />! <br />LOate:........ ___ <br />i Qomment~:_ <br />UJ No <br /> <br />MedAmerica LTC vers: 2.10.0 <br /> <br />'i<i-..-"..,'................'"..~."".~, <br />