Apple Reference & Presentation Library 8 (Internal Edition)

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/ Apple Reference & Presen…rary 8 (Internal Edition) / Apple R&P Lib Internal v8.0.iso / 1-Reference / Electronic Forms / Benefits / Aetna Medical⁄Dental / Aetna Medical_Dental
Unknown | 1990-01-03 | 12.4 KB
open in:
MacOS 8.1 |
Win98 |
DOS
view JSON data |
view as text

This file was not able to be converted.
This format is not currently supported by dexvert.
Confidence	Program	Detection	Match Type	Support
`100%`	file	data	default
`100%`	TrID	Adobe PhotoShop Brush	default (weak)
hex view
+--------+-------------------------+-------------------------+--------+--------+
|00000000| 00 0c 00 02 00 00 00 30 | 00 00 21 22 00 00 01 de |.......0|..!"....|
|00000010| 00 00 1d 1c 00 00 1d 1e | 00 00 30 58 00 00 00 00 |........|..0X....|
|00000020| 00 00 00 00 00 00 00 00 | 00 00 00 00 00 00 00 00 |........|........|
|00000030| 09 90 0c 60 00 01 00 01 | 00 00 00 00 00 01 00 00 |...`....|........|
|00000040| 00 00 00 00 00 03 00 01 | 00 01 00 03 00 00 00 48 |........|.......H|
|00000050| 00 48 00 00 00 00 03 08 | 02 40 ff f8 ff ee 03 10 |.H......|.@......|
|00000060| 02 52 03 47 05 28 03 fc | 00 02 00 00 00 48 00 48 |.R.G.(..|.....H.H|
|00000070| 00 00 00 00 03 08 02 40 | 00 01 00 00 00 64 00 00 |.......@|.....d..|
|00000080| 00 01 00 01 01 01 00 00 | 00 01 27 0f 00 01 00 01 |........|..'.....|
|00000090| 00 00 00 00 00 00 00 00 | 00 00 00 00 00 02 00 19 |........|........|
|000000a0| 01 90 00 00 00 00 00 70 | 00 00 00 00 00 00 00 00 |.......p|........|
|000000b0| 00 00 00 00 00 00 00 00 | 00 00 00 00 00 00 00 00 |........|........|
|000000c0| 00 00 00 00 01 11 00 01 | 00 06 00 06 40 38 00 00 |........|....@8..|
|000000d0| 00 00 00 00 40 38 00 00 | 00 00 00 00 00 19 00 03 |....@8..|........|
|000000e0| 00 01 00 01 00 00 00 03 | 01 26 01 26 00 3c 00 38 |........|.&.&.<.8|
|000000f0| 00 01 00 14 00 01 00 0a | 00 01 5f da 00 00 00 15 |........|.._.....|
|00000100| 00 01 00 0c 00 00 00 00 | 00 00 00 00 00 00 00 00 |........|........|
|00000110| 00 00 00 00 00 00 00 00 | 00 00 00 03 00 00 ff ff |........|........|
|00000120| ff ff ff ff ff ff 00 01 | 00 01 00 4d e5 4e 00 4d |........|...M.N.M|
|00000130| e5 54 00 4a 75 e8 00 4a | 75 e8 00 00 00 00 00 00 |.T.Ju..J|u.......|
|00000140| 00 01 00 01 00 01 00 01 | 00 01 00 01 00 00 00 00 |........|........|
|00000150| 00 00 00 01 00 00 00 00 | 00 00 00 00 00 00 00 90 |........|........|
|00000160| 00 07 00 00 00 01 09 90 | 0c 60 00 20 00 48 0c 3d |........|.`. .H.=|
|00000170| 09 45 00 00 00 00 00 00 | 00 00 00 00 00 00 00 00 |.E......|........|
|00000180| 00 00 00 00 00 00 00 00 | 00 00 00 00 00 00 00 00 |........|........|
|00000190| 00 00 00 00 00 00 00 00 | 00 00 00 00 00 00 00 00 |........|........|
|000001a0| 00 00 00 00 00 00 00 00 | 00 00 00 00 00 00 00 00 |........|........|
|000001b0| 00 00 00 00 00 00 00 00 | 00 00 00 00 00 00 00 00 |........|........|
|000001c0| 00 00 00 00 00 00 00 00 | 00 00 00 00 00 00 00 00 |........|........|
|000001d0| 00 00 00 00 00 00 00 00 | 00 00 00 00 00 00 00 03 |........|........|
|000001e0| 00 00 00 34 00 24 00 4c | 0b d0 09 44 00 01 00 01 |...4.$.L|...D....|
|000001f0| 00 03 00 01 ff ff ff ff | ff ff ff ff 00 00 00 00 |........|........|
|00000200| 00 00 00 00 00 00 00 01 | 00 28 00 28 00 28 00 28 |........|.(.(.(.(|
|00000210| 00 00 00 00 00 00 00 00 | 00 07 00 00 00 70 00 38 |........|.....p.8|
|00000220| 01 3c 00 a4 09 20 00 01 | 00 00 ff ff ff ff ff ff |.<... ..|........|
|00000230| ff ff 00 01 00 00 00 00 | 00 00 00 02 00 38 01 3c |........|.....8.<|
|00000240| 00 a4 09 20 00 00 00 00 | 00 14 00 0e 00 01 00 00 |... ....|........|
|00000250| 00 03 00 03 00 01 00 1c | 41 45 54 4e 41 20 20 4d |........|AETNA  M|
|00000260| 45 44 49 43 41 4c 2f 44 | 45 4e 54 41 4c 20 20 43 |EDICAL/D|ENTAL  C|
|00000270| 4c 41 49 4d 00 00 00 16 | 00 01 00 00 00 00 00 0f |LAIM....|........|
|00000280| 00 0c 00 14 01 00 00 0e | 00 00 00 00 00 00 00 0d |........|........|
|00000290| 00 00 00 cc 00 5c 00 94 | 00 d0 00 fc 00 00 00 00 |.....\..|........|
|000002a0| 00 00 00 00 00 00 00 02 | 00 07 00 00 00 56 00 5c |........|.....V.\|
|000002b0| 00 94 00 d0 00 fa 00 01 | 00 00 ff ff ff ff ff ff |........|........|
|000002c0| ff ff 00 01 00 00 00 00 | 00 00 00 02 00 5c 00 94 |........|.....\..|
|000002d0| 00 d0 00 fa 00 00 00 00 | 00 14 00 18 00 00 00 00 |........|........|
|000002e0| 00 03 00 03 00 01 00 01 | f0 00 00 00 00 16 00 01 |........|........|
|000002f0| 00 00 00 00 00 18 00 12 | 00 14 00 00 00 18 00 00 |........|........|
|00000300| 00 00 00 00 00 07 00 00 | 00 56 00 a1 00 df 00 ba |........|.V......|
|00000310| 00 fc 00 01 00 00 ff ff | ff ff ff ff ff ff 00 01 |........|........|
|00000320| 00 00 00 00 00 00 00 02 | 00 a1 00 df 00 ba 00 fc |........|........|
|00000330| 00 00 00 00 00 14 00 04 | 00 00 00 00 00 03 00 03 |........|........|
|00000340| 00 01 00 01 a8 00 00 00 | 00 16 00 01 00 00 00 00 |........|........|
|00000350| 00 05 00 04 00 14 00 00 | 00 04 00 00 00 00 00 00 |........|........|
|00000360| 00 01 00 00 00 ac 00 b1 | 07 dc 01 41 09 20 00 01 |........|...A. ..|
|00000370| 00 00 00 00 00 15 00 00 | 00 0c 00 00 00 03 00 03 |........|........|
|00000380| 00 00 00 01 00 03 00 01 | 00 00 00 03 00 01 ff ff |........|........|
|00000390| ff ff ff ff ff ff 00 00 | 00 00 00 00 00 00 00 00 |........|........|
|000003a0| 00 03 00 00 ff ff ff ff | ff ff ff ff 00 90 00 90 |........|........|
|000003b0| 00 3c 00 34 00 00 00 f4 | 00 02 00 01 00 00 00 00 |.<.4....|........|
|000003c0| 00 00 00 00 00 00 00 00 | 00 00 00 00 00 02 00 b2 |........|........|
|000003d0| 07 dd 00 ed 09 20 01 01 | 01 01 00 14 00 0a 00 80 |..... ..|........|
|000003e0| 00 00 00 03 00 03 00 01 | 00 0d 45 4d 50 4c 4f 59 |........|..EMPLOY|
|000003f0| 45 45 20 20 4e 4f 2e ad | 00 00 00 16 00 01 00 00 |EE  NO..|........|
|00000400| 00 00 00 0c 00 09 00 14 | 00 00 00 0a 00 00 00 00 |........|........|
|00000410| 00 00 00 01 00 00 00 a2 | 00 b1 06 98 01 41 07 dc |........|.....A..|
|00000420| 00 01 00 00 00 00 00 15 | 00 00 00 0c 00 00 00 03 |........|........|
|00000430| 00 03 00 00 00 01 00 03 | 00 01 00 00 00 03 00 01 |........|........|
|00000440| ff ff ff ff ff ff ff ff | 00 00 00 00 00 00 00 00 |........|........|
|00000450| 00 00 00 03 00 00 ff ff | ff ff ff ff ff ff 00 88 |........|........|
|00000460| 00 88 00 3c 00 38 00 00 | 00 f5 00 01 00 01 00 00 |...<.8..|........|
|00000470| 00 00 00 00 00 00 00 00 | 00 00 00 00 00 00 00 02 |........|........|
|00000480| 00 b2 06 99 00 ed 07 dc | 01 01 01 01 00 14 00 0a |........|........|
|00000490| 00 80 00 00 00 03 00 03 | 00 01 00 04 44 41 54 45 |........|....DATE|
|000004a0| 00 00 00 16 00 01 00 00 | 00 00 00 0c 00 09 00 14 |........|........|
|000004b0| 00 00 00 0a 00 00 00 00 | 00 00 00 01 00 00 00 a8 |........|........|
|000004c0| 01 41 04 df 01 d1 05 de | 00 01 00 00 00 00 00 15 |.A......|........|
|000004d0| 00 00 00 0c 00 00 00 03 | 00 03 00 00 00 01 00 03 |........|........|
|000004e0| 00 01 00 00 00 03 00 01 | ff ff ff ff ff ff ff ff |........|........|
|000004f0| 00 00 00 00 00 00 00 00 | 00 00 00 03 00 00 ff ff |........|........|
|00000500| ff ff ff ff ff ff 00 90 | 00 90 00 3c 00 34 00 00 |........|...<.4..|
|00000510| 00 f6 00 06 00 01 00 00 | 00 00 00 00 00 00 00 00 |........|........|
|00000520| 00 00 00 00 00 00 00 02 | 01 42 04 e0 01 7d 05 de |........|.B...}..|
|00000530| 01 01 01 01 00 14 00 0a | 00 80 00 00 00 03 00 03 |........|........|
|00000540| 00 01 00 0a 4d 41 49 4c | 20 20 53 54 4f 50 00 00 |....MAIL|  STOP..|
|00000550| 00 16 00 01 00 00 00 00 | 00 0c 00 09 00 14 00 00 |........|........|
|00000560| 00 0a 00 00 00 00 00 00 | 00 01 00 00 00 a8 01 41 |........|.......A|
|00000570| 07 dc 01 d1 09 20 00 01 | 00 00 00 00 00 15 00 20 |..... ..|....... |
|00000580| 00 0c 00 00 00 03 00 03 | 00 00 00 01 00 03 00 01 |........|........|
|00000590| 00 00 00 03 00 01 ff ff | ff ff ff ff ff ff 00 00 |........|........|
|000005a0| 00 00 00 00 00 00 00 00 | 00 03 00 00 ff ff ff ff |........|........|
|000005b0| ff ff ff ff 00 94 00 94 | 00 3c 00 38 00 00 00 f7 |........|.<.8....|
|000005c0| 00 08 00 01 00 00 00 00 | 00 00 00 00 00 00 00 00 |........|........|
|000005d0| 00 00 00 00 00 02 01 42 | 07 dd 01 7d 09 20 01 01 |.......B|...}. ..|
|000005e0| 01 01 00 14 00 0a 00 80 | 00 00 00 03 00 03 00 01 |........|........|
|000005f0| 00 09 41 50 50 4c 45 4c | 49 4e 4b 00 00 00 00 16 |..APPLEL|INK.....|
|00000600| 00 01 00 00 00 00 00 0c | 00 09 00 14 00 00 00 0a |........|........|
|00000610| 00 00 00 00 00 00 00 01 | 00 00 00 ac 01 41 05 de |........|.....A..|
|00000620| 01 d1 07 dc 00 01 00 00 | 00 00 00 15 00 00 00 0c |........|........|
|00000630| 00 00 00 03 00 03 00 01 | 00 01 00 03 00 01 00 00 |........|........|
|00000640| 00 03 00 01 ff ff ff ff | ff ff ff ff 00 00 00 00 |........|........|
|00000650| 00 00 00 00 00 00 00 03 | 00 00 ff ff ff ff ff ff |........|........|
|00000660| ff ff 00 90 00 90 00 3c | 00 34 00 00 00 f8 00 07 |.......<|.4......|
|00000670| 00 01 00 00 00 00 00 00 | 00 00 00 00 00 00 00 00 |........|........|
|00000680| 00 00 00 02 01 42 05 df | 01 7d 07 dc 01 01 01 01 |.....B..|.}......|
|00000690| 00 14 00 0a 00 80 00 00 | 00 03 00 03 00 01 00 0e |........|........|
|000006a0| 54 45 4c 45 50 48 4f 4e | 45 20 20 4e 4f 2e 00 00 |TELEPHON|E  NO...|
|000006b0| 00 16 00 01 00 00 00 00 | 00 0c 00 09 00 14 00 00 |........|........|
|000006c0| 00 0a 00 00 00 00 00 00 | 00 01 00 00 00 a6 01 41 |........|.......A|
|000006d0| 03 49 01 d1 04 14 00 01 | 00 00 00 00 00 15 00 00 |.I......|........|
|000006e0| 00 0c 00 00 00 03 00 03 | 00 00 00 01 00 03 00 01 |........|........|
|000006f0| 00 00 00 03 00 01 ff ff | ff ff ff ff ff ff 00 00 |........|........|
|00000700| 00 00 00 00 00 00 00 00 | 00 03 00 00 ff ff ff ff |........|........|
|00000710| ff ff ff ff 00 70 00 70 | 00 3c 00 34 00 00 00 f9 |.....p.p|.<.4....|
|00000720| 00 04 00 01 00 00 00 00 | 00 00 00 00 00 00 00 00 |........|........|
|00000730| 00 00 00 00 00 02 01 42 | 03 4a 01 7d 04 14 01 01 |.......B|.J.}....|
|00000740| 01 01 00 14 00 0a 00 80 | 00 00 00 03 00 03 00 01 |........|........|
|00000750| 00 08 44 49 56 2e 20 4e | 4f 2e 00 00 00 16 00 01 |..DIV. N|O.......|
|00000760| 00 00 00 00 00 0c 00 09 | 00 14 00 00 00 0a 00 00 |........|........|
|00000770| 00 00 00 00 00 01 00 00 | 00 a8 01 41 04 14 01 d1 |........|...A....|
|00000780| 04 df 00 01 00 00 00 00 | 00 15 00 00 00 0c 00 00 |........|........|
|00000790| 00 03 00 03 00 00 00 01 | 00 03 00 01 00 00 00 03 |........|........|
|000007a0| 00 01 ff ff ff ff ff ff | ff ff 00 00 00 00 00 00 |........|........|
|000007b0| 00 00 00 00 00 03 00 00 | ff ff ff ff ff ff ff ff |........|........|
|000007c0| 00 90 00 90 00 3c 00 34 | 00 00 00 fa 00 05 00 01 |.....<.4|........|
|000007d0| 00 00 00 00 00 00 00 00 | 00 00 00 00 00 00 00 00 |........|........|
|000007e0| 00 02 01 42 04 15 01 7d | 04 df 01 01 01 01 00 14 |...B...}|........|
|000007f0| 00 0a 00 80 00 00 00 03 | 00 03 00 01 00 09 44 45 |........|......DE|
|00000800| 50 54 2e 20 4e 4f 2e 61 | 00 00 00 16 00 01 00 00 |PT. NO.a|........|
|00000810| 00 00 00 0c 00 09 00 14 | 00 00 00 0a 00 00 00 00 |........|........|
|00000820| 00 00 00 01 00 00 00 ac | 01 41 00 70 01 d1 03 49 |........|.A.p...I|
|00000830| 00 01 00 00 00 00 00 15 | 00 00 00 0c 00 00 00 03 |........|........|
|00000840| 00 03 00 2a 00 01 00 03 | 00 01 00 00 00 03 00 01 |...*....|........|
|00000850| ff ff ff ff ff ff ff ff | 00 00 00 00 00 00 00 00 |........|........|
|00000860| 00 00 00 03 00 00 ff ff | ff ff ff ff ff ff 01 98 |........|........|
|00000870| 01 98 00 3c 00 38 00 00 | 00 fb 00 03 00 01 00 00 |...<.8..|........|
|00000880| 00 00 00 00 00 00 00 00 | 00 00 00 00 00 00 00 02 |........|........|
|00000890| 01 42 00 71 01 7d 03 49 | 01 01 01 01 00 14 00 0a |.B.q.}.I|........|
|000008a0| 00 80 00 00 00 03 00 03 | 00 01 00 0e 45 4d 50 4c |........|....EMPL|
|000008b0| 4f 59 45 45 20 20 4e 41 | 4d 45 00 00 00 16 00 01 |OYEE  NA|ME......|
|000008c0| 00 00 00 00 00 0c 00 09 | 00 14 00 00 00 0a 00 00 |........|........|
|000008d0| 00 00 00 00 00 02 00 00 | 00 22 00 b1 07 dc 00 ee |........|."......|
|000008e0| 07 dc 00 01 00 00 00 03 | 00 00 00 00 00 00 00 00 |........|........|
|000008f0| 00 00 00 00 00 00 00 00 | 00 00 00 00 00 02 00 00 |........|........|
|00000900| 00 22 01 40 07 dc 01 7e | 07 dc 00 01 00 00 00 03 |.".@...~|........|
|00000910| 00 00 00 00 00 00 00 00 | 00 00 00 00 00 00 00 00 |........|........|
|00000920| 00 00 00 00 00 02 00 00 | 00 22 01 3e 05 de 01 7c |........|.".>...||
|00000930| 05 de 00 01 00 00 00 03 | 00 00 00 00 00 00 00 00 |........|........|
|00000940| 00 00 00 00 00 00 00 00 | 00 00 00 00 00 02 00 00 |........|........|
|00000950| 00 22 01 40 04 de 01 7e | 04 de 00 01 00 00 00 03 |.".@...~|........|
|00000960| 00 00 00 00 00 00 00 00 | 00 00 00 00 00 00 00 00 |........|........|
|00000970| 00 00 00 00 00 02 00 00 | 00 22 01 3e 04 14 01 7c |........|.".>...||
|00000980| 04 14 00 01 00 00 00 03 | 00 00 00 00 00 00 00 00 |........|........|
|00000990| 00 00 00 00 00 00 00 00 | 00 00 00 00 00 02 00 00 |........|........|
|000009a0| 00 22 01 3e 03 48 01 7c | 03 48 00 01 00 00 00 03 |.".>.H.||.H......|
|000009b0| 00 00 00 00 00 00 00 00 | 00 00 00 00 00 00 00 00 |........|........|
|000009c0| 00 00 00 00 00 07 00 00 | 00 68 0b f4 00 4c 0c 3c |........|.h...L.<|
|000009d0| 02 38 00 01 00 01 ff ff | ff ff ff ff ff ff 00 01 |.8......|........|
|000009e0| 00 00 00 00 00 00 00 02 | 0b f4 00 4c 0c 3c 02 38 |........|...L.<.8|
|000009f0| 00 00 00 00 00 14 00 0e | 00 20 00 00 00 01 00 03 |........|. ......|
|00000a00| 00 01 00 14 41 70 70 6c | 65 20 43 6f 6d 70 75 74 |....Appl|e Comput|
|00000a10| 65 72 2c 20 49 6e 63 2e | 00 00 00 16 00 01 00 00 |er, Inc.|........|
|00000a20| 00 00 00 0f 00 0c 00 14 | 20 00 00 0e 00 00 00 00 |........| .......|
|00000a30| 00 00 00 07 00 00 00 62 | 0b f0 08 1c 0c 3c 09 44 |.......b|.....<.D|
|00000a40| 00 01 00 00 ff ff ff ff | ff ff ff ff 00 01 00 00 |........|........|
|00000a50| 00 00 00 00 00 02 0b f0 | 08 1c 0c 3c 09 44 00 00 |........|...<.D..|
|00000a60| 00 00 00 14 00 0a 00 00 | 00 00 00 02 00 03 00 01 |........|........|
|00000a70| 00 0e 42 45 4e 31 30 30 | 20 28 30 31 2f 39 30 29 |..BEN100| (01/90)|
|00000a80| 00 00 00 16 00 01 00 00 | 00 00 00 0c 00 09 00 14 |........|........|
|00000a90| 00 00 00 0a 00 00 00 00 | 00 00 00 01 00 00 00 a8 |........|........|
|00000aa0| 01 d1 00 70 02 60 01 b5 | 00 01 00 00 00 00 00 15 |...p.`..|........|
|00000ab0| 00 00 00 0c 00 00 00 03 | 00 03 00 00 00 01 00 03 |........|........|
|00000ac0| 00 01 00 00 00 03 00 01 | 00 00 00 00 00 00 00 00 |........|........|
|00000ad0| 00 00 00 00 00 00 00 00 | 00 00 00 03 00 00 ff ff |........|........|
|00000ae0| ff ff ff ff ff ff 00 88 | 00 88 00 3c 00 38 00 00 |........|...<.8..|
|00000af0| 01 00 00 09 00 01 00 00 | 00 00 00 00 00 00 00 00 |........|........|
|00000b00| 00 00 00 00 00 00 00 02 | 01 d2 00 71 02 0d 01 b5 |........|...q....|
|00000b10| 01 01 01 01 00 14 00 0a | 00 00 00 00 00 03 00 03 |........|........|
|00000b20| 00 01 00 0a 48 49 52 45 | 20 20 44 41 54 45 00 00 |....HIRE|  DATE..|
|00000b30| 00 16 00 01 00 00 00 00 | 00 0c 00 09 00 14 00 00 |........|........|
|00000b40| 00 0a 00 00 00 00 00 00 | 00 01 00 00 00 b6 01 d1 |........|........|
|00000b50| 04 14 02 e8 09 20 00 01 | 00 00 00 00 00 15 00 00 |..... ..|........|
|00000b60| 00 0c 00 00 00 03 00 01 | 00 00 00 01 00 03 00 01 |........|........|
|00000b70| 00 00 00 03 00 01 00 00 | 00 00 00 00 00 00 00 00 |........|........|
|00000b80| 00 00 00 00 00 00 00 00 | 00 03 00 00 ff ff ff ff |........|........|
|00000b90| ff ff ff ff 01 98 01 98 | 00 3c 00 38 00 00 01 01 |........|.<.8....|
|00000ba0| 00 0b 00 01 00 00 00 00 | 00 00 00 00 00 00 00 00 |........|........|
|00000bb0| 00 00 00 00 00 02 01 d2 | 04 15 02 0d 09 20 01 01 |........|..... ..|
|00000bc0| 01 01 00 14 00 0a 00 00 | 00 00 00 03 00 03 00 01 |........|........|
|00000bd0| 00 17 45 4d 50 4c 4f 59 | 45 45 20 20 48 4f 4d 45 |..EMPLOY|EE  HOME|
|00000be0| 20 20 41 44 44 52 45 53 | 53 00 00 00 00 16 00 01 |  ADDRES|S.......|
|00000bf0| 00 00 00 00 00 0c 00 09 | 00 14 00 00 00 0a 00 00 |........|........|
|00000c00| 00 00 00 00 00 01 00 00 | 00 be 01 d1 01 b5 02 60 |........|.......`|
|00000c10| 04 14 00 01 00 00 00 00 | 00 15 00 00 00 0c 00 00 |........|........|
|00000c20| 00 03 00 03 00 00 00 01 | 00 03 00 01 00 00 00 03 |........|........|
|00000c30| 00 01 00 00 00 00 00 00 | 00 00 00 00 00 00 00 00 |........|........|
|00000c40| 00 00 00 00 00 03 00 00 | ff ff ff ff ff ff ff ff |........|........|
|00000c50| 01 98 01 98 00 3c 00 38 | 00 00 01 02 00 0a 00 01 |.....<.8|........|
|00000c60| 00 00 00 00 00 00 00 00 | 00 00 00 00 00 00 00 00 |........|........|
|00000c70| 00 02 01 d2 01 b6 02 0d | 04 14 01 01 01 01 00 14 |........|........|
|00000c80| 00 0a 00 20 00 00 00 03 | 00 03 00 01 00 1f 45 4d |... ....|......EM|
|00000c90| 50 2e 20 20 20 20 53 4f | 43 49 41 4c 20 20 20 53 |P.    SO|CIAL   S|
|00000ca0| 45 43 55 52 49 54 59 20 | 20 20 4e 4f 2e 3c 00 00 |ECURITY |  NO.<..|
|00000cb0| 00 16 00 01 00 00 00 00 | 00 0c 00 09 00 14 20 00 |........|...... .|
|00000cc0| 00 0a 00 00 00 00 00 00 | 00 01 00 00 00 b2 02 60 |........|.......`|
|00000cd0| 00 70 02 e8 04 14 00 01 | 00 00 00 00 00 15 00 00 |.p......|........|
|00000ce0| 00 0c 00 00 00 03 00 03 | 00 01 00 01 00 03 00 01 |........|........|
|00000cf0| 00 00 00 03 00 01 00 00 | 00 00 00 00 00 00 00 00 |........|........|
|00000d00| 00 00 00 00 00 00 00 00 | 00 03 00 00 ff ff ff ff |........|........|
|00000d10| ff ff ff ff 00 90 00 90 | 00 3c 00 34 00 00 01 03 |........|.<.4....|
|00000d20| 00 0c 00 01 00 00 00 00 | 00 00 00 00 00 00 00 00 |........|........|
|00000d30| 00 00 00 00 00 02 02 61 | 00 71 02 9c 04 14 01 01 |.......a|.q......|
|00000d40| 01 01 00 14 00 0a 00 00 | 00 00 00 03 00 03 00 01 |........|........|
|00000d50| 00 14 48 4f 4d 45 20 20 | 54 45 4c 45 50 48 4f 4e |..HOME  |TELEPHON|
|00000d60| 45 20 20 4e 4f 2e 00 00 | 00 16 00 01 00 00 00 00 |E  NO...|........|
|00000d70| 00 0c 00 09 00 14 00 00 | 00 0a 00 00 00 00 00 00 |........|........|
|00000d80| 00 07 00 00 00 b8 05 40 | 01 af 05 81 06 10 00 01 |.......@|........|
|00000d90| 00 00 ff ff ff ff ff ff | ff ff 00 01 00 00 00 00 |........|........|
|00000da0| 00 00 00 02 05 40 01 af | 05 81 06 10 00 00 00 00 |.....@..|........|
|00000db0| 00 14 00 0c ff 00 00 00 | 00 03 00 03 00 01 00 3b |........|.......;|
|00000dc0| a5 20 44 6f 20 79 6f 75 | 20 77 69 73 68 20 62 65 |. Do you| wish be|
|00000dd0| 6e 65 66 69 74 73 20 74 | 6f 20 62 65 20 70 61 69 |nefits t|o be pai|
|00000de0| 64 20 64 69 72 65 63 74 | 6c 79 20 74 6f 20 74 68 |d direct|ly to th|
|00000df0| 65 20 70 72 6f 76 69 64 | 65 72 3f 0c 00 00 00 3e |e provid|er?....>|
|00000e00| 00 03 00 00 00 00 00 0c | 00 09 00 14 00 00 00 0c |........|........|
|00000e10| 00 00 00 00 00 00 00 00 | 00 01 00 0c 00 09 00 14 |........|........|
|00000e20| 01 00 00 0c 00 00 00 00 | 00 00 00 00 00 02 00 0c |........|........|
|00000e30| 00 09 00 14 00 00 00 0c | 00 00 00 00 00 00 00 07 |........|........|
|00000e40| 00 00 00 86 05 a3 01 af | 05 e4 06 61 00 01 00 00 |........|...a....|
|00000e50| ff ff ff ff ff ff ff ff | 00 01 00 00 00 00 00 00 |........|........|
|00000e60| 00 02 05 a3 01 af 05 e4 | 06 61 00 00 00 00 00 14 |........|.a......|
|00000e70| 00 0c ff 00 00 00 00 01 | 00 03 00 01 00 1d a5 20 |........|....... |
|00000e80| 49 73 20 63 6c 61 69 6d | 20 66 6f 72 20 61 6e 20 |Is claim| for an |
|00000e90| 61 63 63 69 64 65 6e 74 | 3f 20 20 23 00 00 00 2a |accident|?  #...*|
|00000ea0| 00 02 00 00 00 00 00 0c | 00 09 00 14 01 00 00 0c |........|........|
|00000eb0| 00 00 00 00 00 00 00 00 | 00 02 00 0c 00 09 00 14 |........|........|
|00000ec0| 00 00 00 0c 00 00 00 00 | 00 00 00 01 00 00 00 ee |........|........|
|00000ed0| 06 02 01 ff 06 ea 07 e3 | 00 01 00 00 00 00 00 15 |........|........|
|00000ee0| 00 00 00 0c 00 00 00 01 | 00 01 00 00 00 01 00 03 |........|........|
|00000ef0| 00 00 00 00 00 04 00 01 | 00 00 00 00 00 00 00 00 |........|........|
|00000f00| 00 00 00 00 00 00 00 00 | 00 03 00 03 00 00 ff ff |........|........|
|00000f10| ff ff ff ff ff ff 01 68 | 01 68 00 3c 00 34 00 00 |.......h|.h.<.4..|
|00000f20| 01 04 00 18 00 01 00 00 | 00 00 00 00 00 00 00 00 |........|........|
|00000f30| 00 00 00 00 00 00 00 02 | 06 02 01 ff 06 3e 07 e4 |........|.....>..|
|00000f40| 01 01 80 81 00 14 00 0c | ff 00 00 00 00 01 00 03 |........|........|
|00000f50| 00 01 00 3c 49 46 20 59 | 45 53 2c 20 20 69 6e 64 |...<IF Y|ES,  ind|
|00000f60| 69 63 61 74 65 20 68 6f | 77 2c 20 77 68 65 6e 20 |icate ho|w, when |
|00000f70| 61 6e 64 20 77 68 65 72 | 65 20 74 68 65 20 61 63 |and wher|e the ac|
|00000f80| 63 69 64 65 6e 74 20 6f | 63 63 75 72 72 65 64 3a |cident o|ccurred:|
|00000f90| 00 00 00 2a 00 02 00 00 | 00 00 00 0c 00 09 00 14 |...*....|........|
|00000fa0| 01 00 00 0c 00 00 00 00 | 00 00 00 00 00 06 00 0c |........|........|
|00000fb0| 00 09 00 14 00 00 00 0c | 00 00 00 00 00 00 00 01 |........|........|
|00000fc0| 00 00 00 bc 07 26 00 70 | 07 7c 09 20 00 01 00 00 |.....&.p|.|. ....|
|00000fd0| 00 00 00 15 00 00 00 0c | 00 00 00 03 00 03 00 00 |........|........|
|00000fe0| 00 01 00 02 00 00 00 00 | 00 04 00 01 00 00 00 00 |........|........|
|00000ff0| 00 00 00 00 00 00 00 00 | 00 00 00 00 00 00 00 03 |........|........|
|00001000| 00 00 ff ff ff ff ff ff | ff ff 03 14 01 68 00 28 |........|.....h.(|
|00001010| 00 38 00 00 01 05 00 00 | 00 00 00 00 00 00 00 00 |.8......|........|
|00001020| 00 00 00 00 00 00 00 00 | 00 00 00 02 07 26 00 70 |........|.....&.p|
|00001030| 07 7d 03 84 01 01 81 80 | 00 14 00 0e 00 01 00 00 |.}......|........|
|00001040| 00 03 00 03 00 01 00 1e | 41 75 74 68 6f 72 69 7a |........|Authoriz|
|00001050| 65 64 20 50 65 72 73 6f | 6e d5 73 20 53 69 67 6e |ed Perso|n.s Sign|
|00001060| 61 74 75 72 65 3a 00 00 | 00 16 00 01 00 00 00 00 |ature:..|........|
|00001070| 00 0f 00 0c 00 14 01 00 | 00 0e 00 00 00 00 00 00 |........|........|
|00001080| 00 01 00 00 00 a2 04 d6 | 06 77 05 17 07 23 00 01 |........|.w...#..|
|00001090| 00 00 00 00 00 15 00 00 | 00 0c 00 00 00 03 00 03 |........|........|
|000010a0| 00 01 00 01 00 04 00 00 | 00 00 00 00 00 01 00 00 |........|........|
|000010b0| 00 00 00 00 00 00 00 00 | 00 00 00 00 00 00 00 03 |........|........|
|000010c0| 00 03 00 00 ff ff ff ff | ff ff ff ff 00 38 00 6c |........|.....8.l|
|000010d0| 00 14 00 20 00 00 01 06 | 00 12 00 01 00 00 00 00 |... ....|........|
|000010e0| 00 00 00 00 00 00 00 00 | 00 00 00 00 00 02 04 d6 |........|........|
|000010f0| 06 b7 05 18 07 24 01 00 | 81 81 00 14 00 0c 00 00 |.....$..|........|
|00001100| 00 00 00 03 00 03 00 01 | 00 03 59 45 53 2e 00 00 |........|..YES...|
|00001110| 00 16 00 01 00 00 00 00 | 00 0c 00 09 00 14 00 00 |........|........|
|00001120| 00 0c 00 00 00 00 00 00 | 00 01 00 00 00 a0 04 d6 |........|........|
|00001130| 07 47 05 17 07 f3 00 01 | 00 00 00 00 00 15 00 00 |.G......|........|
|00001140| 00 0c 00 00 00 03 00 03 | 00 01 00 01 00 04 00 00 |........|........|
|00001150| 00 00 00 00 00 01 00 00 | 00 00 00 00 00 00 00 00 |........|........|
|00001160| 00 00 00 00 00 00 00 03 | 00 03 00 00 ff ff ff ff |........|........|
|00001170| ff ff ff ff 00 38 00 6c | 00 14 00 20 00 00 01 07 |.....8.l|... ....|
|00001180| 00 13 00 01 00 00 00 00 | 00 00 00 00 00 00 00 00 |........|........|
|00001190| 00 00 00 00 00 02 04 d6 | 07 87 05 18 07 f4 01 00 |........|........|
|000011a0| 81 81 00 14 00 0c 00 00 | 00 00 00 03 00 03 00 01 |........|........|
|000011b0| 00 02 4e 4f 00 00 00 16 | 00 01 00 00 00 00 00 0c |..NO....|........|
|000011c0| 00 09 00 14 00 00 00 0c | 00 00 00 00 00 00 00 01 |........|........|
|000011d0| 00 00 00 a2 05 40 06 77 | 05 81 07 23 00 01 00 00 |.....@.w|...#....|
|000011e0| 00 00 00 15 00 00 00 0c | 00 00 00 03 00 03 00 01 |........|........|
|000011f0| 00 01 00 04 00 00 00 00 | 00 00 00 01 00 00 00 00 |........|........|
|00001200| 00 00 00 00 00 00 00 00 | 00 00 00 00 00 03 00 03 |........|........|
|00001210| 00 00 ff ff ff ff ff ff | ff ff 00 38 00 6c 00 14 |........|...8.l..|
|00001220| 00 20 00 00 01 08 00 14 | 00 01 00 00 00 00 00 00 |. ......|........|
|00001230| 00 00 00 00 00 00 00 00 | 00 00 00 02 05 40 06 b7 |........|.....@..|
|00001240| 05 82 07 24 01 00 81 81 | 00 14 00 0c 00 00 00 00 |...$....|........|
|00001250| 00 03 00 03 00 01 00 03 | 59 45 53 6e 00 00 00 16 |........|YESn....|
|00001260| 00 01 00 00 00 00 00 0c | 00 09 00 14 00 00 00 0c |........|........|
|00001270| 00 00 00 00 00 00 00 01 | 00 00 00 a0 05 40 07 47 |........|.....@.G|
|00001280| 05 81 07 f3 00 01 00 00 | 00 00 00 15 00 00 00 0c |........|........|
|00001290| 00 00 00 03 00 03 00 01 | 00 01 00 04 00 00 00 00 |........|........|
|000012a0| 00 00 00 01 00 00 00 00 | 00 00 00 00 00 00 00 00 |........|........|
|000012b0| 00 00 00 00 00 03 00 03 | 00 00 ff ff ff ff ff ff |........|........|
|000012c0| ff ff 00 38 00 6c 00 14 | 00 20 00 00 01 09 00 15 |...8.l..|. ......|
|000012d0| 00 01 00 00 00 00 00 00 | 00 00 00 00 00 00 00 00 |........|........|
|000012e0| 00 00 00 02 05 40 07 87 | 05 82 07 f4 01 00 81 81 |.....@..|........|
|000012f0| 00 14 00 0c 00 00 00 00 | 00 03 00 03 00 01 00 02 |........|........|
|00001300| 4e 4f 00 00 00 16 00 01 | 00 00 00 00 00 0c 00 09 |NO......|........|
|00001310| 00 14 00 00 00 0c 00 00 | 00 00 00 00 00 01 00 00 |........|........|
|00001320| 00 a2 05 a3 06 77 05 e4 | 07 23 00 01 00 00 00 00 |.....w..|.#......|
|00001330| 00 15 00 00 00 0c 00 00 | 00 03 00 03 00 01 00 01 |........|........|
|00001340| 00 04 00 00 00 00 00 00 | 00 01 00 00 00 00 00 00 |........|........|
|00001350| 00 00 00 00 00 00 00 00 | 00 00 00 03 00 03 00 00 |........|........|
|00001360| ff ff ff ff ff ff ff ff | 00 38 00 6c 00 14 00 20 |........|.8.l... |
|00001370| 00 00 01 0a 00 16 00 01 | 00 00 00 00 00 00 00 00 |........|........|
|00001380| 00 00 00 00 00 00 00 00 | 00 02 05 a3 06 b7 05 e5 |........|........|
|00001390| 07 24 01 00 81 81 00 14 | 00 0c 00 00 00 00 00 03 |.$......|........|
|000013a0| 00 03 00 01 00 03 59 45 | 53 00 00 00 00 16 00 01 |......YE|S.......|
|000013b0| 00 00 00 00 00 0c 00 09 | 00 14 00 00 00 0c 00 00 |........|........|
|000013c0| 00 00 00 00 00 01 00 00 | 00 a0 05 a3 07 47 05 e4 |........|.....G..|
|000013d0| 07 f3 00 01 00 00 00 00 | 00 15 00 00 00 0c 00 00 |........|........|
|000013e0| 00 03 00 03 00 01 00 01 | 00 04 00 00 00 00 00 00 |........|........|
|000013f0| 00 01 00 00 00 00 00 00 | 00 00 00 00 00 00 00 00 |........|........|
|00001400| 00 00 00 03 00 03 00 00 | ff ff ff ff ff ff ff ff |........|........|
|00001410| 00 38 00 6c 00 14 00 20 | 00 00 01 0b 00 17 00 01 |.8.l... |........|
|00001420| 00 00 00 00 00 00 00 00 | 00 00 00 00 00 00 00 00 |........|........|
|00001430| 00 02 05 a3 07 87 05 e5 | 07 f4 01 00 81 81 00 14 |........|........|
|00001440| 00 0c 00 00 00 00 00 03 | 00 03 00 01 00 02 4e 4f |........|......NO|
|00001450| 00 00 00 16 00 01 00 00 | 00 00 00 0c 00 09 00 14 |........|........|
|00001460| 00 00 00 0c 00 00 00 00 | 00 00 00 07 00 00 00 9e |........|........|
|00001470| 04 d6 01 af 05 17 06 10 | 00 01 00 00 ff ff ff ff |........|........|
|00001480| ff ff ff ff 00 01 00 00 | 00 00 00 00 00 02 04 d6 |........|........|
|00001490| 01 af 05 17 06 10 00 00 | 00 00 00 14 00 0c ff 00 |........|........|
|000014a0| 00 00 00 01 00 03 00 01 | 00 22 a5 20 49 73 20 63 |........|.". Is c|
|000014b0| 6f 6e 64 69 74 69 6f 6e | 20 65 6d 70 6c 6f 79 6d |ondition| employm|
|000014c0| 65 6e 74 20 72 65 6c 61 | 74 65 64 3f 00 00 00 3e |ent rela|ted?...>|
|000014d0| 00 03 00 00 00 00 00 0c | 00 09 00 14 00 00 00 0c |........|........|
|000014e0| 00 00 00 00 00 00 00 00 | 00 01 00 0c 00 09 00 14 |........|........|
|000014f0| 01 00 00 0c 00 00 00 00 | 00 00 00 00 00 02 00 0c |........|........|
|00001500| 00 09 00 14 00 00 00 0c | 00 00 00 00 00 00 00 03 |........|........|
|00001510| 00 00 00 34 07 d7 00 70 | 0b 77 09 20 00 01 00 00 |...4...p|.w. ....|
|00001520| 00 03 00 00 ff ff ff ff | ff ff ff ff 00 00 80 00 |........|........|
|00001530| 00 00 08 00 00 00 00 01 | 00 28 00 28 00 28 00 28 |........|.(.(.(.(|
|00001540| 00 00 00 00 00 00 00 00 | 00 01 00 00 00 ae 03 03 |........|........|
|00001550| 00 5c 03 40 04 b8 00 01 | 00 00 00 00 00 15 00 00 |.\.@....|........|
|00001560| 00 0c 00 00 00 03 00 02 | 00 2a 00 01 00 02 00 00 |........|.*......|
|00001570| 00 00 00 04 00 01 00 00 | 00 00 00 00 00 00 00 00 |........|........|
|00001580| 00 00 00 00 00 00 00 01 | 00 03 00 00 ff ff ff ff |........|........|
|00001590| ff ff ff ff 01 58 01 58 | 00 29 00 29 00 00 01 0c |.....X.X|.).)....|
|000015a0| 00 0d 00 01 00 00 00 00 | 00 00 00 00 00 00 00 00 |........|........|
|000015b0| 00 00 00 00 00 02 03 03 | 00 5c 03 41 01 b4 01 01 |........|.\.A....|
|000015c0| 81 80 00 14 00 0c 00 01 | 00 00 00 03 00 02 00 01 |........|........|
|000015d0| 00 0f 50 61 74 69 65 6e | 74 d5 73 20 4e 61 6d 65 |..Patien|t.s Name|
|000015e0| 3a f2 00 00 00 16 00 01 | 00 00 00 00 00 0c 00 09 |:.......|........|
|000015f0| 00 14 01 00 00 0c 00 00 | 00 00 00 00 00 07 00 00 |........|........|
|00001600| 00 82 04 04 01 af 04 3d | 05 f3 00 01 00 00 ff ff |.......=|........|
|00001610| ff ff ff ff ff ff 00 01 | 00 00 00 00 00 00 00 02 |........|........|
|00001620| 04 04 01 af 04 3d 05 f3 | 00 00 00 00 00 14 00 0c |.....=..|........|
|00001630| 00 00 00 00 00 01 00 02 | 00 01 00 2d a5 20 41 72 |........|...-. Ar|
|00001640| 65 20 62 65 6e 65 66 69 | 74 73 20 61 76 61 69 6c |e benefi|ts avail|
|00001650| 61 62 6c 65 20 66 72 6f | 6d 20 6f 74 68 65 72 20 |able fro|m other |
|00001660| 63 6f 76 65 72 61 67 65 | 3f 1c 00 00 00 16 00 01 |coverage|?.......|
|00001670| 00 00 00 00 00 0c 00 09 | 00 14 00 00 00 0c 00 00 |........|........|
|00001680| 00 00 00 00 00 01 00 00 | 00 ec 04 4f 01 fb 04 9f |........|...O....|
|00001690| 07 df 00 01 00 00 00 00 | 00 15 00 00 00 0c 00 00 |........|........|
|000016a0| 00 03 00 02 00 00 00 01 | 00 02 00 00 00 00 00 04 |........|........|
|000016b0| 00 01 00 00 00 00 00 00 | 00 00 00 00 00 00 00 00 |........|........|
|000016c0| 00 00 00 03 00 03 00 00 | ff ff ff ff ff ff ff ff |........|........|
|000016d0| 02 f8 01 68 00 30 00 34 | 00 00 01 0d 00 11 00 01 |...h.0.4|........|
|000016e0| 00 00 00 00 00 00 00 00 | 00 00 00 00 00 00 00 00 |........|........|
|000016f0| 00 02 04 4f 01 fb 04 a0 | 04 f3 01 01 81 80 00 14 |...O....|........|
|00001700| 00 0c ff 00 00 00 00 01 | 00 02 00 01 00 26 20 20 |........|.....&  |
|00001710| 49 46 20 59 45 53 20 2c | 20 20 50 6c 65 61 73 65 |IF YES ,|  Please|
|00001720| 20 69 64 65 6e 74 69 66 | 79 20 20 63 6f 76 65 72 | identif|y  cover|
|00001730| 61 67 65 3a 00 00 00 3e | 00 03 00 00 00 00 00 0c |age:...>|........|
|00001740| 00 09 00 14 01 00 00 0c | 00 00 00 00 00 00 00 00 |........|........|
|00001750| 00 0c 00 0c 00 09 00 14 | 00 00 00 0c 00 00 00 00 |........|........|
|00001760| 00 00 00 00 00 25 00 0c | 00 09 00 14 01 00 00 0c |.....%..|........|
|00001770| 00 00 00 00 00 00 00 01 | 00 00 00 a2 03 fc 06 77 |........|.......w|
|00001780| 04 3d 07 23 00 01 00 00 | 00 00 00 15 00 00 00 0c |.=.#....|........|
|00001790| 00 00 00 03 00 03 00 01 | 00 01 00 04 00 00 00 00 |........|........|
|000017a0| 00 00 00 01 00 00 00 00 | 00 00 00 00 00 00 00 00 |........|........|
|000017b0| 00 00 00 00 00 03 00 03 | 00 00 ff ff ff ff ff ff |........|........|
|000017c0| ff ff 00 38 00 6c 00 14 | 00 20 00 00 01 0e 00 0f |...8.l..|. ......|
|000017d0| 00 01 00 00 00 00 00 00 | 00 00 00 00 00 00 00 00 |........|........|
|000017e0| 00 00 00 02 03 fc 06 b7 | 04 3e 07 24 01 00 81 81 |........|.>.$....|
|000017f0| 00 14 00 0c 00 00 00 00 | 00 03 00 03 00 01 00 03 |........|........|
|00001800| 59 45 53 3c 00 00 00 16 | 00 01 00 00 00 00 00 0c |YES<....|........|
|00001810| 00 09 00 14 00 00 00 0c | 00 00 00 00 00 00 00 01 |........|........|
|00001820| 00 00 00 a0 03 fc 07 47 | 04 3d 07 f3 00 01 00 00 |.......G|.=......|
|00001830| 00 00 00 15 00 00 00 0c | 00 00 00 03 00 03 00 01 |........|........|
|00001840| 00 01 00 04 00 00 00 00 | 00 00 00 01 00 00 00 00 |........|........|
|00001850| 00 00 00 00 00 00 00 00 | 00 00 00 00 00 03 00 03 |........|........|
|00001860| 00 00 ff ff ff ff ff ff | ff ff 00 38 00 6c 00 14 |........|...8.l..|
|00001870| 00 20 00 00 01 0f 00 10 | 00 01 00 00 00 00 00 00 |. ......|........|
|00001880| 00 00 00 00 00 00 00 00 | 00 00 00 02 03 fc 07 87 |........|........|
|00001890| 04 3e 07 f4 01 00 81 81 | 00 14 00 0c 00 00 00 00 |.>......|........|
|000018a0| 00 03 00 03 00 01 00 02 | 4e 4f 00 00 00 16 00 01 |........|NO......|
|000018b0| 00 00 00 00 00 0c 00 09 | 00 14 00 00 00 0c 00 00 |........|........|
|000018c0| 00 00 00 00 00 01 00 00 | 00 c4 03 04 04 6c 03 44 |........|.....l.D|
|000018d0| 09 20 00 01 00 00 00 00 | 00 15 00 00 00 0c 00 00 |. ......|........|
|000018e0| 00 03 00 02 00 00 00 01 | 00 02 00 00 00 00 00 04 |........|........|
|000018f0| 00 01 00 00 00 00 00 00 | 00 00 00 00 00 00 00 00 |........|........|
|00001900| 00 00 00 01 00 03 00 00 | ff ff ff ff ff ff ff ff |........|........|
|00001910| 03 50 01 68 00 28 00 2c | 00 00 01 10 00 0e 00 01 |.P.h.(.,|........|
|00001920| 00 00 00 00 00 00 00 00 | 00 00 00 00 00 00 00 00 |........|........|
|00001930| 00 02 03 04 04 6c 03 45 | 07 bc 01 01 81 80 00 14 |.....l.E|........|
|00001940| 00 0c 00 01 00 00 00 02 | 00 02 00 01 00 26 50 6c |........|.....&Pl|
|00001950| 65 61 73 65 20 69 6e 64 | 69 63 61 74 65 20 77 68 |ease ind|icate wh|
|00001960| 6f 20 74 68 69 73 20 63 | 6c 61 69 6d 20 69 73 20 |o this c|laim is |
|00001970| 66 6f 72 3a 00 00 00 16 | 00 01 00 00 00 00 00 0c |for:....|........|
|00001980| 00 09 00 14 01 00 00 0c | 00 00 00 00 00 00 00 07 |........|........|
|00001990| 00 00 00 6c 03 44 07 27 | 03 7c 09 40 00 01 00 00 |...l.D.'|.|.@....|
|000019a0| ff ff ff ff ff ff ff ff | 00 01 00 00 00 00 00 00 |........|........|
|000019b0| 00 02 03 44 07 27 03 7c | 09 40 00 00 00 00 00 14 |...D.'.||.@......|
|000019c0| 00 0c 00 00 00 00 00 03 | 00 03 00 01 00 18 28 53 |........|......(S|
|000019d0| 65 6c 66 2c 20 53 70 6f | 75 73 65 2c 20 6f 72 20 |elf, Spo|use, or |
|000019e0| 43 68 69 6c 64 29 00 00 | 00 16 00 01 00 00 00 00 |Child)..|........|
|000019f0| 00 0c 00 09 00 14 00 00 | 00 0c 00 00 00 00 00 00 |........|........|
|00001a00| 00 07 00 00 00 ea 0a d4 | 00 98 0b 72 09 48 00 01 |........|...r.H..|
|00001a10| 00 00 ff ff ff ff ff ff | ff ff 00 01 00 00 00 00 |........|........|
|00001a20| 00 00 00 02 0a d4 00 98 | 0b 72 09 48 00 00 00 00 |........|.r.H....|
|00001a30| 00 14 00 0c 00 01 00 00 | 00 03 00 03 00 02 00 95 |........|........|
|00001a40| 41 6e 79 20 70 65 72 73 | 6f 6e 20 77 68 6f 20 69 |Any pers|on who i|
|00001a50| 6e 74 65 6e 74 69 6f 6e | 61 6c 6c 79 20 6d 61 6b |ntention|ally mak|
|00001a60| 65 73 20 61 20 73 74 61 | 74 65 6d 65 6e 74 20 6f |es a sta|tement o|
|00001a70| 66 20 63 6c 61 69 6d 20 | 63 6f 6e 74 61 69 6e 69 |f claim |containi|
|00001a80| 6e 67 20 61 6e 79 20 6d | 61 74 65 72 69 61 6c 6c |ng any m|ateriall|
|00001a90| 79 20 66 61 6c 73 65 2c | 20 20 69 6e 63 6f 6d 70 |y false,|  incomp|
|00001aa0| 6c 65 74 65 20 0d 6f 72 | 20 6d 69 73 6c 65 61 64 |lete .or| mislead|
|00001ab0| 69 6e 67 20 69 6e 66 6f | 72 6d 61 74 69 6f 6e 20 |ing info|rmation |
|00001ac0| 69 73 20 67 75 69 6c 74 | 79 20 6f 66 20 61 20 63 |is guilt|y of a c|
|00001ad0| 72 69 6d 65 2e 00 00 00 | 00 16 00 01 00 00 00 00 |rime....|........|
|00001ae0| 00 0c 00 09 00 14 01 00 | 00 0c 00 00 00 00 00 00 |........|........|
|00001af0| 00 07 00 00 01 a6 08 6f | 02 d3 0a f0 06 ab 00 01 |.......o|........|
|00001b00| 00 00 ff ff ff ff ff ff | ff ff 00 01 00 00 00 00 |........|........|
|00001b10| 00 00 00 02 08 6f 02 d3 | 0a f0 06 ab 00 00 00 00 |.....o..|........|
|00001b20| 00 14 00 0c ff 00 00 00 | 00 01 00 01 00 0c 01 3e |........|.......>|
|00001b30| 31 2e 20 20 41 74 74 61 | 63 68 20 69 74 65 6d 69 |1.  Atta|ch itemi|
|00001b40| 7a 65 64 20 62 69 6c 6c | 20 74 6f 20 74 68 69 73 |zed bill| to this|
|00001b50| 20 63 6c 61 69 6d 20 66 | 6f 72 6d 2e 0d 0d 32 2e | claim f|orm...2.|
|00001b60| 20 20 4d 61 69 6c 20 63 | 6c 61 69 6d 20 74 6f 3a |  Mail c|laim to:|
|00001b70| 0d 20 20 20 20 20 20 20 | 20 20 20 41 65 74 6e 61 |.       |   Aetna|
|00001b80| 20 4c 69 66 65 20 49 6e | 73 75 72 61 6e 63 65 0d | Life In|surance.|
|00001b90| 20 20 20 20 20 20 20 20 | 20 20 45 6d 70 6c 6f 79 |        |  Employ|
|00001ba0| 65 65 20 42 65 6e 65 66 | 69 74 20 43 6c 61 69 6d |ee Benef|it Claim|
|00001bb0| 73 20 44 65 70 61 72 74 | 6d 65 6e 74 0d 20 20 20 |s Depart|ment.   |
|00001bc0| 20 20 20 20 20 20 20 50 | 2e 4f 2e 20 42 6f 78 20 |       P|.O. Box |
|00001bd0| 31 32 33 34 30 0d 20 20 | 20 20 20 20 20 20 20 20 |12340.  |        |
|00001be0| 46 72 65 73 6e 6f 2c 20 | 43 41 2e 20 20 39 33 37 |Fresno, |CA.  937|
|00001bf0| 36 35 0d 0d 33 2e 20 20 | 49 66 20 79 6f 75 20 68 |65..3.  |If you h|
|00001c00| 61 76 65 20 61 6e 79 20 | 71 75 65 73 74 69 6f 6e |ave any |question|
|00001c10| 73 20 6f 72 20 70 72 6f | 62 6c 65 6d 73 2c 20 70 |s or pro|blems, p|
|00001c20| 6c 65 61 73 65 20 0d 20 | 20 20 20 20 63 61 6c 6c |lease . |    call|
|00001c30| 20 6f 72 20 4c 69 6e 6b | 20 41 45 54 4e 41 20 61 | or Link| AETNA a|
|00001c40| 74 3a 0d 0d 20 20 20 20 | 20 20 20 20 20 20 20 20 |t:..    |        |
|00001c50| 31 2d 38 30 30 20 2d 20 | 34 32 31 2d 36 38 31 39 |1-800 - |421-6819|
|00001c60| 20 6f 72 20 4c 69 6e 6b | 20 41 45 54 4e 41 00 00 | or Link| AETNA..|
|00001c70| 00 2a 00 02 00 00 00 00 | 00 0c 00 09 00 14 00 00 |.*......|........|
|00001c80| 00 0c 00 00 00 00 00 00 | 00 00 01 20 00 0c 00 09 |........|... ....|
|00001c90| 00 14 01 00 00 0c 00 00 | 00 00 00 00 00 07 00 00 |........|........|
|00001ca0| 00 78 07 f2 02 37 08 2c | 06 e7 00 01 00 00 ff ff |.x...7.,|........|
|00001cb0| ff ff ff ff ff ff 00 01 | 00 00 00 00 00 00 00 02 |........|........|
|00001cc0| 07 f2 02 37 08 2c 06 e7 | 00 00 00 00 00 14 00 0e |...7.,..|........|
|00001cd0| 00 05 00 00 00 01 00 01 | 00 01 00 23 49 4e 53 54 |........|...#INST|
|00001ce0| 52 55 43 54 49 4f 4e 53 | 20 46 4f 52 20 53 55 42 |RUCTIONS| FOR SUB|
|00001cf0| 4d 49 54 54 49 4e 47 20 | 43 4c 41 49 4d 53 3a 00 |MITTING |CLAIMS:.|
|00001d00| 00 00 00 16 00 01 00 00 | 00 00 00 0f 00 0c 00 14 |........|........|
|00001d10| 05 00 00 0e 00 00 00 00 | 00 00 00 00 00 00 00 03 |........|........|
|00001d20| 00 00 00 34 00 10 00 10 | 0c 50 09 80 00 01 00 00 |...4....|.P......|
|00001d30| 00 03 00 01 ff ff ff ff | ff ff ff ff 00 00 00 00 |........|........|
|00001d40| 00 00 00 00 00 00 00 01 | 00 28 00 28 00 28 00 28 |........|.(.(.(.(|
|00001d50| 00 00 00 00 00 00 00 00 | 00 07 00 00 00 a2 01 6c |........|.......l|
|00001d60| 00 10 01 d8 09 80 00 01 | 00 00 ff ff ff ff ff ff |........|........|
|00001d70| ff ff 00 01 00 00 00 00 | 00 00 00 02 01 6c 00 10 |........|.....l..|
|00001d80| 01 d8 09 80 00 00 00 00 | 00 15 00 0c 00 00 00 00 |........|........|
|00001d90| 00 03 00 03 00 01 00 4e | 50 4c 45 41 53 45 20 55 |.......N|PLEASE U|
|00001da0| 53 45 20 54 48 45 20 54 | 41 42 20 4b 45 59 20 54 |SE THE T|AB KEY T|
|00001db0| 4f 20 4d 4f 56 45 20 46 | 52 4f 4d 20 20 46 49 45 |O MOVE F|ROM  FIE|
|00001dc0| 4c 44 20 54 4f 20 46 49 | 45 4c 44 20 57 48 45 4e |LD TO FI|ELD WHEN|
|00001dd0| 20 46 49 4c 4c 49 4e 47 | 20 4f 55 54 20 54 48 49 | FILLING| OUT THI|
|00001de0| 53 20 46 4f 52 4d 00 00 | 00 16 00 01 00 00 00 00 |S FORM..|........|
|00001df0| 00 0e 00 0a 00 15 00 00 | 00 0c 00 00 00 00 00 00 |........|........|
|00001e00| 00 07 00 00 00 70 00 74 | 00 10 00 ec 06 20 00 01 |.....p.t|..... ..|
|00001e10| 00 00 ff ff ff ff ff ff | ff ff 00 01 00 00 00 00 |........|........|
|00001e20| 00 00 00 02 00 74 00 10 | 00 ec 06 20 00 00 00 00 |.....t..|... ....|
|00001e30| 00 14 00 0e 00 01 00 00 | 00 03 00 03 00 01 00 1c |........|........|
|00001e40| 41 45 54 4e 41 20 20 4d | 45 44 49 43 41 4c 2f 44 |AETNA  M|EDICAL/D|
|00001e50| 45 4e 54 41 4c 20 20 43 | 4c 41 49 4d 00 00 00 16 |ENTAL  C|LAIM....|
|00001e60| 00 01 00 00 00 00 00 0f | 00 0c 00 14 01 00 00 0e |........|........|
|00001e70| 00 00 00 00 00 00 00 07 | 00 00 00 b4 01 fc 00 b8 |........|........|
|00001e80| 03 13 04 df 00 01 00 00 | ff ff ff ff ff ff ff ff |........|........|
|00001e90| 00 01 00 00 00 00 00 00 | 00 02 01 fc 00 b8 03 13 |........|........|
|00001ea0| 04 df 00 00 00 00 00 15 | 00 0c 00 01 00 00 00 03 |........|........|
|00001eb0| 00 03 00 05 00 5f 46 4f | 52 20 48 45 4c 50 20 43 |....._FO|R HELP C|
|00001ec0| 41 4c 4c 20 54 48 45 20 | 42 45 4e 45 46 49 54 53 |ALL THE |BENEFITS|
|00001ed0| 20 48 45 4c 50 20 44 45 | 53 4b 3a 0d 0d 4d 4f 4e | HELP DE|SK:..MON|
|00001ee0| 44 41 59 20 54 4f 20 46 | 52 49 44 41 59 0d 28 34 |DAY TO F|RIDAY.(4|
|00001ef0| 30 38 29 20 39 37 34 2d | 32 32 37 35 0d 37 3a 30 |08) 974-|2275.7:0|
|00001f00| 30 20 41 4d 20 20 74 6f | 20 20 35 3a 33 30 20 50 |0 AM  to|  5:30 P|
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|00002e80| 75 20 77 65 72 65 20 68 | 69 72 65 64 2e 73 00 04 |u were h|ired.s..|
|00002e90| 00 00 00 00 00 00 00 00 | 00 00 00 00 ff ff ff f6 |........|........|
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|00002ee0| 00 01 00 00 00 00 00 01 | 00 00 00 00 00 00 00 00 |........|........|
|00002ef0| 00 00 00 00 00 00 00 00 | 00 00 00 00 00 51 50 6c |........|.....QPl|
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|00002f50| 00 04 00 00 00 00 00 00 | 00 00 00 00 00 00 ff ff |........|........|
|00002f60| ff f7 00 05 00 01 ff ff | 00 00 00 00 00 03 00 00 |........|........|
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|00002f80| 00 00 00 00 00 00 00 00 | 00 00 00 00 00 00 00 00 |........|........|
|00002f90| 00 00 00 00 00 00 01 02 | 00 00 00 01 00 0a 00 00 |........|........|
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|00002fb0| 00 00 00 00 00 00 00 00 | 00 00 00 00 00 00 00 53 |........|.......S|
|00002fc0| 50 6c 65 61 73 65 20 65 | 6e 74 65 72 20 79 6f 75 |Please e|nter you|
|00002fd0| 72 20 73 6f 63 69 61 6c | 20 73 65 63 75 72 69 74 |r social| securit|
|00002fe0| 79 20 6e 75 6d 62 65 72 | 2c 20 75 73 69 6e 67 20 |y number|, using |
|00002ff0| 74 68 65 20 66 6f 6c 6c | 6f 77 69 6e 67 20 66 6f |the foll|owing fo|
|00003000| 72 6d 61 74 3a 20 20 31 | 31 31 2d 32 32 2d 33 33 |rmat:  1|11-22-33|
|00003010| 33 33 0d 73 00 04 00 00 | 00 00 00 00 00 00 00 00 |33.s....|........|
|00003020| 00 00 ff ff ff f8 00 05 | 00 01 ff f3 00 00 00 00 |........|........|
|00003030| 00 03 00 00 00 00 00 01 | 00 00 00 00 00 00 00 00 |........|........|
|00003040| 00 00 00 00 00 00 00 00 | 00 00 00 00 00 00 00 00 |........|........|
|00003050| 00 00 00 00 00 00 00 00 | 00 06 00 01 14 41 65 74 |........|.....Aet|
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|00003070| 6c 61 a1 1d f1 98 a1 c7 | e2 b4 00 01 ff f5 00 00 |la......|........|
|00003080| 00 02 00 00 00 07 46 46 | 00 00 00 00 00 00 00 04 |......FF|........|
|00003090| 00 00 00 04 00 00 00 00 | 00 03 00 00 00 00 46 46 |........|......FF|
|000030a0| 00 00 00 00 00 00 00 ee | 00 2a 00 58 00 58 00 58 |........|.*.X.X.X|
|000030b0| 00 58 00 58 00 58 00 58 | 00 5c 00 5c 00 60 00 62 |.X.X.X.X|.\.\.`.b|
|000030c0| 00 66 00 68 00 6c 00 70 | 00 70 00 70 00 70 00 74 |.f.h.l.p|.p.p.p.t|
|000030d0| 00 78 00 7e 00 88 00 8c | 00 90 00 a3 00 aa 00 ae |.x.~....|........|
|000030e0| 00 ae 00 bb 00 c5 00 c5 | 00 c5 00 c7 00 c9 00 cb |........|........|
|000030f0| 00 cd 00 cf 00 d1 00 e4 | 00 e4 00 e6 00 e8 00 ee |........|........|
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|00003110| a1 c7 e3 19 a1 c7 e3 19 | 00 01 86 9f a1 c6 f1 00 |........|........|
|00003120| 00 04 39 39 2d 41 01 98 | 03 e7 27 0f ff ff ff ff |..99-A..|..'.....|
|00003130| 00 00 00 63 00 00 03 e7 | 00 11 53 6d 61 72 74 00 |...c....|..Smart.|
|00003140| 42 65 61 00 00 00 00 00 | 00 00 00 00 05 53 4d 41 |Bea.....|.....SMA|
|00003150| 52 54 a1 2e 03 00 00 0b | 39 39 39 2d 39 39 2d 39 |RT......|999-99-9|
|00003160| 39 39 39 01 98 00 de 08 | ae ff ff ff ff 00 00 00 |999.....|........|
|00003170| 01 00 01 00 00 00 00 00 | 01 00 11 53 6d 61 72 74 |........|...Smart|
|00003180| 00 42 65 61 00 00 00 00 | 00 00 00 00 00 00 00 01 |.Bea....|........|
|00003190| 00 04 53 65 6c 66 00 00 | 00 15 00 01 00 00 00 00 |..Self..|........|
|000031a0| 45 45                   |                         |EE      |        |
+--------+-------------------------+-------------------------+--------+--------+