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Simpl city. Administrative Offices: 165 Court Street Rochester, NY 14647 Home Office: Fargo, ND AF~ILlA TION WORKSHEET ent: Rhonda Peterson Address: 451013 Ave S Far 0, ND 58121-0004 City State Zip License #: Phone #: 701-282-1595 Fax #: 701-277-2454 o Other Is L TCi current offered or Sponsored? .................................... 0 Yes Number of Employees/Members.......................... ................. Location of Employees ........................................... 0 Single State BUlin Information: Select BUlin Method 'i. Direct Bill to Employee o . Employer PaidlBilled to Employer (Check One) CJ Annual CJ Monthly Note: Payroll Deduction requires completion of separate forms and must have a minimum of 10 a Iications submitted to ether as a rou . AFFILIATION COMMITMENT The above named Affiliation has selected the Agent named below as Agent of Record to market BlueCross BlueShield of North Dakota long term care insurance to all its eligible employees/members. In addition, the Affiliation agrees to support the Agent of Record in the implementation of a communication and enrollment program to all its eligible em 10 ees/members. * Signature of ffiliation Reft)esentative K r.e.1--e r s o~ Agent of Record Name 'l "'~ \, r')()O l( Date /) A- w L dS Producer Code Signature of Agent of Record Date Send completed form to: L TCI Sales Department or 165 Court Street Rochester, NY 14647 Fax completed form to: (585) 238-3642 "For Company Use Only Exclusive Group (Check One) I 8 I Yes 18 I No Grouo Number: Comments: Aooroval: Date: * GrouD exclusivitv is at the discretion of BlueCross BlueShield of North Dakota. Noridian Mutual Insurance Company