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MacOS 8.1

Win98

DOS

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+--------+-------------------------+-------------------------+--------+--------+
|00000000| 00 16 43 75 73 74 6f 6d | 20 43 6f 76 2f 48 65 61 |..Custom| Cov/Hea|
|00000010| 6c 74 68 20 43 61 72 65 | 00 00 00 00 00 00 00 00 |lth Care|........|
|00000020| 00 00 00 00 00 00 00 00 | 00 00 00 00 00 00 00 00 |........|........|
|00000030| 00 00 00 00 00 00 00 00 | 00 00 00 00 00 00 00 00 |........|........|
|00000040| 00 53 54 43 4b 4b 43 46 | 4d 01 00 00 00 00 00 00 |.STCKKCF|M.......|
|00000050| 00 00 00 00 00 2e 86 00 | 00 02 8f a1 74 78 ee a1 |........|....tx..|
|00000060| 96 ae 3c 00 00 00 00 00 | 00 00 00 00 00 00 00 00 |..<.....|........|
|00000070| 00 00 00 00 00 00 00 00 | 00 00 81 81 4a 2b 00 00 |........|....J+..|
|00000080| 00 0c 00 02 00 00 00 30 | 00 00 20 20 00 00 01 de |.......0|..  ....|
|00000090| 00 00 1c a2 00 00 1c a4 | 00 00 2c d2 00 00 00 00 |........|..,.....|
|000000a0| 00 00 00 00 00 00 00 00 | 00 00 00 00 00 00 00 00 |........|........|
|000000b0| 09 90 0c 60 00 01 00 01 | 00 00 00 00 00 01 00 00 |...`....|........|
|000000c0| 00 00 00 00 00 03 00 01 | 00 00 00 03 00 00 00 48 |........|.......H|
|000000d0| 00 48 00 00 00 00 03 08 | 02 40 ff f8 ff ee 03 10 |.H......|.@......|
|000000e0| 02 52 03 47 05 28 03 fc | 00 02 00 00 00 48 00 48 |.R.G.(..|.....H.H|
|000000f0| 00 00 00 00 03 08 02 40 | 00 01 00 00 00 64 00 00 |.......@|.....d..|
|00000100| 00 01 00 01 01 01 00 00 | 00 01 27 0f 00 01 00 01 |........|..'.....|
|00000110| 00 00 00 00 00 00 00 00 | 00 00 00 00 00 02 00 19 |........|........|
|00000120| 01 90 00 00 00 00 00 70 | 00 00 00 00 00 00 00 00 |.......p|........|
|00000130| 00 00 00 00 00 00 00 00 | 00 00 00 00 00 00 00 00 |........|........|
|00000140| 00 00 00 00 01 27 00 01 | 00 06 00 06 40 38 00 00 |.....'..|....@8..|
|00000150| 00 00 00 00 40 38 00 00 | 00 00 00 00 00 10 00 03 |....@8..|........|
|00000160| 00 01 00 01 00 00 00 03 | 01 26 01 26 00 3c 00 38 |........|.&.&.<.8|
|00000170| 00 01 00 14 00 01 00 0a | 00 01 5f da 00 00 00 15 |........|.._.....|
|00000180| 00 01 00 0c 00 00 00 00 | 00 00 00 00 00 00 00 00 |........|........|
|00000190| 00 00 00 00 00 00 00 00 | 00 00 00 03 00 00 ff ff |........|........|
|000001a0| ff ff ff ff ff ff 00 01 | 00 01 00 4d e5 4e 00 4d |........|...M.N.M|
|000001b0| e5 54 00 4a 75 e8 00 4a | 75 e8 00 00 00 00 00 00 |.T.Ju..J|u.......|
|000001c0| 00 01 00 01 00 01 00 01 | 00 01 00 01 00 00 00 00 |........|........|
|000001d0| 00 00 00 01 00 00 00 00 | 00 00 00 00 00 00 00 90 |........|........|
|000001e0| 00 07 00 00 00 01 09 90 | 0c 60 00 20 00 48 0c 3d |........|.`. .H.=|
|000001f0| 09 45 00 00 00 00 00 00 | 00 00 00 00 00 00 00 00 |.E......|........|
|00000200| 00 00 00 00 00 00 00 00 | 00 00 00 00 00 00 00 00 |........|........|
|00000210| 00 00 00 00 00 00 00 00 | 00 00 00 00 00 00 00 00 |........|........|
|00000220| 00 00 00 00 00 00 00 00 | 00 00 00 00 00 00 00 00 |........|........|
|00000230| 00 00 00 00 00 00 00 00 | 00 00 00 00 00 00 00 00 |........|........|
|00000240| 00 00 00 00 00 00 00 00 | 00 00 00 00 00 00 00 00 |........|........|
|00000250| 00 00 00 00 00 00 00 00 | 00 00 00 00 00 00 00 03 |........|........|
|00000260| 00 00 00 34 00 24 00 4c | 0b d0 09 44 00 01 00 01 |...4.$.L|...D....|
|00000270| 00 03 00 01 ff ff ff ff | ff ff ff ff 00 00 00 00 |........|........|
|00000280| 00 00 00 00 00 00 00 01 | 00 28 00 28 00 28 00 28 |........|.(.(.(.(|
|00000290| 00 00 00 00 00 00 00 00 | 00 07 00 00 00 64 00 38 |........|.....d.8|
|000002a0| 01 3c 00 a4 09 20 00 01 | 00 00 ff ff ff ff ff ff |.<... ..|........|
|000002b0| ff ff 00 01 00 00 00 00 | 00 00 00 02 00 38 01 3c |........|.....8.<|
|000002c0| 00 a4 09 20 00 00 00 00 | 00 14 00 0e 00 01 00 00 |... ....|........|
|000002d0| 00 03 00 03 00 01 00 10 | 43 55 53 54 4f 4d 20 43 |........|CUSTOM C|
|000002e0| 4f 56 45 52 41 47 45 0d | 00 00 00 16 00 01 00 00 |OVERAGE.|........|
|000002f0| 00 00 00 0f 00 0c 00 14 | 01 00 00 0e 00 00 00 00 |........|........|
|00000300| 00 00 00 0d 00 00 00 cc | 00 5c 00 94 00 d0 00 fc |........|.\......|
|00000310| 00 00 00 00 00 00 00 00 | 00 00 00 02 00 07 00 00 |........|........|
|00000320| 00 56 00 5c 00 94 00 d0 | 00 fa 00 01 00 00 ff ff |.V.\....|........|
|00000330| ff ff ff ff ff ff 00 01 | 00 00 00 00 00 00 00 02 |........|........|
|00000340| 00 5c 00 94 00 d0 00 fa | 00 00 00 00 00 14 00 18 |.\......|........|
|00000350| 00 00 00 00 00 03 00 03 | 00 01 00 01 f0 00 00 00 |........|........|
|00000360| 00 16 00 01 00 00 00 00 | 00 18 00 12 00 14 00 00 |........|........|
|00000370| 00 18 00 00 00 00 00 00 | 00 07 00 00 00 56 00 a1 |........|.....V..|
|00000380| 00 df 00 ba 00 fc 00 01 | 00 00 ff ff ff ff ff ff |........|........|
|00000390| ff ff 00 01 00 00 00 00 | 00 00 00 02 00 a1 00 df |........|........|
|000003a0| 00 ba 00 fc 00 00 00 00 | 00 14 00 04 00 00 00 00 |........|........|
|000003b0| 00 03 00 03 00 01 00 01 | a8 00 00 00 00 16 00 01 |........|........|
|000003c0| 00 00 00 00 00 05 00 04 | 00 14 00 00 00 04 00 00 |........|........|
|000003d0| 00 00 00 00 00 01 00 00 | 00 ac 00 b1 07 dc 01 41 |........|.......A|
|000003e0| 09 20 00 01 00 00 00 00 | 00 15 00 00 00 0c 00 00 |. ......|........|
|000003f0| 00 03 00 03 00 00 00 01 | 00 03 00 01 00 00 00 03 |........|........|
|00000400| 00 01 ff ff ff ff ff ff | ff ff 00 00 00 00 00 00 |........|........|
|00000410| 00 00 00 00 00 03 00 00 | ff ff ff ff ff ff ff ff |........|........|
|00000420| 00 90 00 90 00 3c 00 34 | 00 00 00 f4 00 02 00 01 |.....<.4|........|
|00000430| 00 00 00 00 00 00 00 00 | 00 00 00 00 00 00 00 00 |........|........|
|00000440| 00 02 00 b2 07 dd 00 ed | 09 20 01 01 01 01 00 14 |........|. ......|
|00000450| 00 0a 00 80 00 00 00 03 | 00 03 00 01 00 0d 45 4d |........|......EM|
|00000460| 50 4c 4f 59 45 45 20 20 | 4e 4f 2e ff 00 00 00 16 |PLOYEE  |NO......|
|00000470| 00 01 00 00 00 00 00 0c | 00 09 00 14 00 00 00 0a |........|........|
|00000480| 00 00 00 00 00 00 00 01 | 00 00 00 a2 00 b1 06 98 |........|........|
|00000490| 01 41 07 dc 00 01 00 00 | 00 00 00 15 00 00 00 0c |.A......|........|
|000004a0| 00 00 00 03 00 03 00 00 | 00 01 00 03 00 01 00 00 |........|........|
|000004b0| 00 03 00 01 ff ff ff ff | ff ff ff ff 00 00 00 00 |........|........|
|000004c0| 00 00 00 00 00 00 00 03 | 00 00 ff ff ff ff ff ff |........|........|
|000004d0| ff ff 00 88 00 88 00 3c | 00 38 00 00 00 f5 00 01 |.......<|.8......|
|000004e0| 00 01 00 00 00 00 00 00 | 00 00 00 00 00 00 00 00 |........|........|
|000004f0| 00 00 00 02 00 b2 06 99 | 00 ed 07 dc 01 01 01 01 |........|........|
|00000500| 00 14 00 0a 00 80 00 00 | 00 03 00 03 00 01 00 04 |........|........|
|00000510| 44 41 54 45 00 00 00 16 | 00 01 00 00 00 00 00 0c |DATE....|........|
|00000520| 00 09 00 14 00 00 00 0a | 00 00 00 00 00 00 00 01 |........|........|
|00000530| 00 00 00 a8 01 41 04 df | 01 d1 05 de 00 01 00 00 |.....A..|........|
|00000540| 00 00 00 15 00 00 00 0c | 00 00 00 03 00 03 00 00 |........|........|
|00000550| 00 01 00 03 00 01 00 00 | 00 03 00 01 ff ff ff ff |........|........|
|00000560| ff ff ff ff 00 00 00 00 | 00 00 00 00 00 00 00 03 |........|........|
|00000570| 00 00 ff ff ff ff ff ff | ff ff 00 90 00 90 00 3c |........|.......<|
|00000580| 00 34 00 00 00 f6 00 06 | 00 01 00 00 00 00 00 00 |.4......|........|
|00000590| 00 00 00 00 00 00 00 00 | 00 00 00 02 01 42 04 e0 |........|.....B..|
|000005a0| 01 7d 05 de 01 01 01 01 | 00 14 00 0a 00 80 00 00 |.}......|........|
|000005b0| 00 03 00 03 00 01 00 0a | 4d 41 49 4c 20 20 53 54 |........|MAIL  ST|
|000005c0| 4f 50 00 00 00 16 00 01 | 00 00 00 00 00 0c 00 09 |OP......|........|
|000005d0| 00 14 00 00 00 0a 00 00 | 00 00 00 00 00 01 00 00 |........|........|
|000005e0| 00 a8 01 41 07 dc 01 d1 | 09 20 00 01 00 00 00 00 |...A....|. ......|
|000005f0| 00 15 00 20 00 0c 00 00 | 00 03 00 03 00 00 00 01 |... ....|........|
|00000600| 00 03 00 01 00 00 00 03 | 00 01 ff ff ff ff ff ff |........|........|
|00000610| ff ff 00 00 00 00 00 00 | 00 00 00 00 00 03 00 00 |........|........|
|00000620| ff ff ff ff ff ff ff ff | 00 94 00 94 00 3c 00 38 |........|.....<.8|
|00000630| 00 00 00 f7 00 08 00 01 | 00 00 00 00 00 00 00 00 |........|........|
|00000640| 00 00 00 00 00 00 00 00 | 00 02 01 42 07 dd 01 7d |........|...B...}|
|00000650| 09 20 01 01 01 01 00 14 | 00 0a 00 80 00 00 00 03 |. ......|........|
|00000660| 00 03 00 01 00 09 41 50 | 50 4c 45 4c 49 4e 4b 01 |......AP|PLELINK.|
|00000670| 00 00 00 16 00 01 00 00 | 00 00 00 0c 00 09 00 14 |........|........|
|00000680| 00 00 00 0a 00 00 00 00 | 00 00 00 01 00 00 00 ac |........|........|
|00000690| 01 41 05 de 01 d1 07 dc | 00 01 00 00 00 00 00 15 |.A......|........|
|000006a0| 00 00 00 0c 00 00 00 03 | 00 03 00 01 00 01 00 03 |........|........|
|000006b0| 00 01 00 00 00 03 00 01 | ff ff ff ff ff ff ff ff |........|........|
|000006c0| 00 00 00 00 00 00 00 00 | 00 00 00 03 00 00 ff ff |........|........|
|000006d0| ff ff ff ff ff ff 00 90 | 00 90 00 3c 00 34 00 00 |........|...<.4..|
|000006e0| 00 f8 00 07 00 01 00 00 | 00 00 00 00 00 00 00 00 |........|........|
|000006f0| 00 00 00 00 00 00 00 02 | 01 42 05 df 01 7d 07 dc |........|.B...}..|
|00000700| 01 01 01 01 00 14 00 0a | 00 80 00 00 00 03 00 03 |........|........|
|00000710| 00 01 00 0e 54 45 4c 45 | 50 48 4f 4e 45 20 20 4e |....TELE|PHONE  N|
|00000720| 4f 2e 00 00 00 16 00 01 | 00 00 00 00 00 0c 00 09 |O.......|........|
|00000730| 00 14 00 00 00 0a 00 00 | 00 00 00 00 00 01 00 00 |........|........|
|00000740| 00 a6 01 41 03 49 01 d1 | 04 14 00 01 00 00 00 00 |...A.I..|........|
|00000750| 00 15 00 00 00 0c 00 00 | 00 03 00 03 00 00 00 01 |........|........|
|00000760| 00 03 00 01 00 00 00 03 | 00 01 ff ff ff ff ff ff |........|........|
|00000770| ff ff 00 00 00 00 00 00 | 00 00 00 00 00 03 00 00 |........|........|
|00000780| ff ff ff ff ff ff ff ff | 00 70 00 70 00 3c 00 34 |........|.p.p.<.4|
|00000790| 00 00 00 f9 00 04 00 01 | 00 00 00 00 00 00 00 00 |........|........|
|000007a0| 00 00 00 00 00 00 00 00 | 00 02 01 42 03 4a 01 7d |........|...B.J.}|
|000007b0| 04 14 01 01 01 01 00 14 | 00 0a 00 80 00 00 00 03 |........|........|
|000007c0| 00 03 00 01 00 08 44 49 | 56 2e 20 4e 4f 2e 00 00 |......DI|V. NO...|
|000007d0| 00 16 00 01 00 00 00 00 | 00 0c 00 09 00 14 00 00 |........|........|
|000007e0| 00 0a 00 00 00 00 00 00 | 00 01 00 00 00 a8 01 41 |........|.......A|
|000007f0| 04 14 01 d1 04 df 00 01 | 00 00 00 00 00 15 00 00 |........|........|
|00000800| 00 0c 00 00 00 03 00 03 | 00 00 00 01 00 03 00 01 |........|........|
|00000810| 00 00 00 03 00 01 ff ff | ff ff ff ff ff ff 00 00 |........|........|
|00000820| 00 00 00 00 00 00 00 00 | 00 03 00 00 ff ff ff ff |........|........|
|00000830| ff ff ff ff 00 90 00 90 | 00 3c 00 34 00 00 00 fa |........|.<.4....|
|00000840| 00 05 00 01 00 00 00 00 | 00 00 00 00 00 00 00 00 |........|........|
|00000850| 00 00 00 00 00 02 01 42 | 04 15 01 7d 04 df 01 01 |.......B|...}....|
|00000860| 01 01 00 14 00 0a 00 80 | 00 00 00 03 00 03 00 01 |........|........|
|00000870| 00 09 44 45 50 54 2e 20 | 4e 4f 2e 1a 00 00 00 16 |..DEPT. |NO......|
|00000880| 00 01 00 00 00 00 00 0c | 00 09 00 14 00 00 00 0a |........|........|
|00000890| 00 00 00 00 00 00 00 01 | 00 00 00 ac 01 41 00 70 |........|.....A.p|
|000008a0| 01 d1 03 49 00 01 00 00 | 00 00 00 15 00 00 00 0c |...I....|........|
|000008b0| 00 00 00 03 00 03 00 2a | 00 01 00 03 00 01 00 00 |.......*|........|
|000008c0| 00 03 00 01 ff ff ff ff | ff ff ff ff 00 00 00 00 |........|........|
|000008d0| 00 00 00 00 00 00 00 03 | 00 00 ff ff ff ff ff ff |........|........|
|000008e0| ff ff 01 98 01 98 00 3c | 00 38 00 00 00 fb 00 03 |.......<|.8......|
|000008f0| 00 01 00 00 00 00 00 00 | 00 00 00 00 00 00 00 00 |........|........|
|00000900| 00 00 00 02 01 42 00 71 | 01 7d 03 49 01 01 01 01 |.....B.q|.}.I....|
|00000910| 00 14 00 0a 00 80 00 00 | 00 03 00 03 00 01 00 0e |........|........|
|00000920| 45 4d 50 4c 4f 59 45 45 | 20 20 4e 41 4d 45 00 00 |EMPLOYEE|  NAME..|
|00000930| 00 16 00 01 00 00 00 00 | 00 0c 00 09 00 14 00 00 |........|........|
|00000940| 00 0a 00 00 00 00 00 00 | 00 02 00 00 00 22 00 b1 |........|....."..|
|00000950| 07 dc 00 ee 07 dc 00 01 | 00 00 00 03 00 00 00 00 |........|........|
|00000960| 00 00 00 00 00 00 00 00 | 00 00 00 00 00 00 00 00 |........|........|
|00000970| 00 02 00 00 00 22 01 40 | 07 dc 01 7e 07 dc 00 01 |.....".@|...~....|
|00000980| 00 00 00 03 00 00 00 00 | 00 00 00 00 00 00 00 00 |........|........|
|00000990| 00 00 00 00 00 00 00 00 | 00 02 00 00 00 22 01 3e |........|.....".>|
|000009a0| 05 de 01 7c 05 de 00 01 | 00 00 00 03 00 00 00 00 |...|....|........|
|000009b0| 00 00 00 00 00 00 00 00 | 00 00 00 00 00 00 00 00 |........|........|
|000009c0| 00 02 00 00 00 22 01 40 | 04 de 01 7e 04 de 00 01 |.....".@|...~....|
|000009d0| 00 00 00 03 00 00 00 00 | 00 00 00 00 00 00 00 00 |........|........|
|000009e0| 00 00 00 00 00 00 00 00 | 00 02 00 00 00 22 01 3e |........|.....".>|
|000009f0| 04 14 01 7c 04 14 00 01 | 00 00 00 03 00 00 00 00 |...|....|........|
|00000a00| 00 00 00 00 00 00 00 00 | 00 00 00 00 00 00 00 00 |........|........|
|00000a10| 00 02 00 00 00 22 01 3e | 03 48 01 7c 03 48 00 01 |.....".>|.H.|.H..|
|00000a20| 00 00 00 03 00 00 00 00 | 00 00 00 00 00 00 00 00 |........|........|
|00000a30| 00 00 00 00 00 00 00 00 | 00 07 00 00 00 68 0b f4 |........|.....h..|
|00000a40| 00 4c 0c 3c 02 38 00 01 | 00 01 ff ff ff ff ff ff |.L.<.8..|........|
|00000a50| ff ff 00 01 00 00 00 00 | 00 00 00 02 0b f4 00 4c |........|.......L|
|00000a60| 0c 3c 02 38 00 00 00 00 | 00 14 00 0e 00 20 00 00 |.<.8....|..... ..|
|00000a70| 00 01 00 03 00 01 00 14 | 41 70 70 6c 65 20 43 6f |........|Apple Co|
|00000a80| 6d 70 75 74 65 72 2c 20 | 49 6e 63 2e 00 00 00 16 |mputer, |Inc.....|
|00000a90| 00 01 00 00 00 00 00 0f | 00 0c 00 14 20 00 00 0e |........|.... ...|
|00000aa0| 00 00 00 00 00 00 00 07 | 00 00 00 62 0b f4 08 1c |........|...b....|
|00000ab0| 0c 3c 09 44 00 01 00 00 | ff ff ff ff ff ff ff ff |.<.D....|........|
|00000ac0| 00 01 00 00 00 00 00 00 | 00 02 0b f4 08 1c 0c 3c |........|.......<|
|00000ad0| 09 44 00 00 00 00 00 14 | 00 0a 00 00 00 00 00 02 |.D......|........|
|00000ae0| 00 03 00 01 00 0e 42 45 | 4e 33 30 30 20 28 31 31 |......BE|N300 (11|
|00000af0| 2f 38 39 29 00 00 00 16 | 00 01 00 00 00 00 00 0c |/89)....|........|
|00000b00| 00 09 00 14 00 00 00 0a | 00 00 00 00 00 00 00 07 |........|........|
|00000b10| 00 00 00 66 00 a8 01 3c | 01 38 06 98 00 01 00 00 |...f...<|.8......|
|00000b20| ff ff ff ff ff ff ff ff | 00 01 00 00 00 00 00 00 |........|........|
|00000b30| 00 02 00 a8 01 3c 01 38 | 06 98 00 00 00 00 00 14 |.....<.8|........|
|00000b40| 00 0c 00 01 00 00 00 03 | 00 03 00 01 00 12 48 45 |........|......HE|
|00000b50| 41 4c 54 48 20 43 41 52 | 45 20 43 4c 41 49 4d 20 |ALTH CAR|E CLAIM |
|00000b60| 00 00 00 16 00 01 00 00 | 00 00 00 0c 00 09 00 14 |........|........|
|00000b70| 01 00 00 0c 00 00 00 00 | 00 00 00 01 00 00 00 ae |........|........|
|00000b80| 01 d0 03 49 02 60 09 20 | 00 01 00 00 00 00 00 15 |...I.`. |........|
|00000b90| 00 00 00 0c 00 00 00 03 | 00 03 00 00 00 01 00 03 |........|........|
|00000ba0| 00 01 00 00 00 03 00 01 | 00 00 00 00 00 00 00 00 |........|........|
|00000bb0| 00 00 00 00 00 00 00 00 | 00 00 00 03 00 00 ff ff |........|........|
|00000bc0| ff ff ff ff ff ff 01 98 | 01 98 00 3c 00 38 00 00 |........|...<.8..|
|00000bd0| 01 1a 00 0a 00 01 00 00 | 00 00 00 00 00 00 00 00 |........|........|
|00000be0| 00 00 00 00 00 00 00 02 | 01 d1 03 4a 02 0c 09 20 |........|...J... |
|00000bf0| 01 01 01 01 00 14 00 0a | 00 00 00 00 00 03 00 03 |........|........|
|00000c00| 00 01 00 10 20 20 57 4f | 52 4b 20 20 4c 4f 43 41 |....  WO|RK  LOCA|
|00000c10| 54 49 4f 4e 00 00 00 16 | 00 01 00 00 00 00 00 0c |TION....|........|
|00000c20| 00 09 00 14 00 00 00 0a | 00 00 00 00 00 00 00 01 |........|........|
|00000c30| 00 00 00 c0 01 d0 00 70 | 02 60 03 49 00 01 00 00 |.......p|.`.I....|
|00000c40| 00 00 00 15 00 00 00 0c | 00 00 00 03 00 03 00 00 |........|........|
|00000c50| 00 01 00 03 00 01 00 00 | 00 03 00 01 00 00 00 00 |........|........|
|00000c60| 00 00 00 00 00 00 00 00 | 00 00 00 00 00 00 00 03 |........|........|
|00000c70| 00 00 ff ff ff ff ff ff | ff ff 01 98 01 98 00 3c |........|.......<|
|00000c80| 00 38 00 00 01 1b 00 09 | 00 01 00 00 00 00 00 00 |.8......|........|
|00000c90| 00 00 00 00 00 00 00 00 | 00 00 00 02 01 d1 00 71 |........|.......q|
|00000ca0| 02 0c 03 49 01 01 01 01 | 00 14 00 0a 00 00 00 00 |...I....|........|
|00000cb0| 00 03 00 03 00 01 00 22 | 45 4d 50 4c 4f 59 45 45 |......."|EMPLOYEE|
|00000cc0| 20 20 20 53 4f 43 49 41 | 4c 20 20 20 53 45 43 55 |   SOCIA|L   SECU|
|00000cd0| 52 49 54 59 20 20 20 4e | 4f 2e 00 00 00 16 00 01 |RITY   N|O.......|
|00000ce0| 00 00 00 00 00 0c 00 09 | 00 14 00 00 00 0a 00 00 |........|........|
|00000cf0| 00 00 00 00 00 03 00 00 | 00 34 02 b0 00 70 0a 54 |........|.4...p.T|
|00000d00| 09 20 00 01 00 00 00 03 | 00 00 ff ff ff ff ff ff |. ......|........|
|00000d10| ff ff 00 00 00 00 00 00 | 00 00 00 00 00 01 00 28 |........|.......(|
|00000d20| 00 28 00 28 00 28 00 00 | 00 00 00 00 00 00 00 07 |.(.(.(..|........|
|00000d30| 00 00 00 56 04 4c 07 8d | 04 f3 07 95 00 01 00 00 |...V.L..|........|
|00000d40| 88 22 88 22 88 22 88 22 | 00 01 00 00 00 00 00 00 |."."."."|........|
|00000d50| 00 02 04 4c 07 8d 04 f3 | 07 95 00 00 00 00 00 15 |...L....|........|
|00000d60| 00 0c 00 00 00 00 00 01 | 00 01 00 02 00 02 0d 0d |........|........|
|00000d70| 00 00 00 16 00 01 00 00 | 00 00 00 0e 00 0a 00 15 |........|........|
|00000d80| 00 00 00 0c 00 00 00 00 | 00 00 00 01 00 00 00 a2 |........|........|
|00000d90| 09 c0 07 09 0a 50 08 c5 | 00 01 00 00 00 00 00 15 |.....P..|........|
|00000da0| 00 00 00 0c 00 00 00 03 | 00 02 00 00 00 01 00 05 |........|........|
|00000db0| 00 00 00 00 00 04 00 01 | 00 00 00 00 00 00 00 00 |........|........|
|00000dc0| 00 00 00 00 00 00 00 00 | 00 00 00 03 00 00 ff ff |........|........|
|00000dd0| ff ff ff ff ff ff 00 d4 | 00 d4 00 14 00 3c 00 00 |........|.....<..|
|00000de0| 01 1c 00 00 00 00 00 00 | 00 00 00 00 00 00 00 00 |........|........|
|00000df0| 00 00 00 00 00 00 00 02 | 0a 14 07 09 0a 51 08 c6 |........|.....Q..|
|00000e00| 00 01 81 81 00 14 00 0a | 00 00 00 00 00 03 00 01 |........|........|
|00000e10| 00 01 00 04 44 41 54 45 | 00 00 00 16 00 01 00 00 |....DATE|........|
|00000e20| 00 00 00 0c 00 09 00 14 | 00 00 00 0a 00 00 00 00 |........|........|
|00000e30| 00 00 00 01 00 00 00 a8 | 09 c0 01 08 0a 50 05 a8 |........|.....P..|
|00000e40| 00 01 00 00 00 00 00 15 | 00 00 00 0c 00 00 00 03 |........|........|
|00000e50| 00 02 00 0a 00 01 00 05 | 00 00 00 00 00 04 00 01 |........|........|
|00000e60| 00 00 00 00 00 00 00 00 | 00 00 00 00 00 00 00 00 |........|........|
|00000e70| 00 00 00 03 00 00 ff ff | ff ff ff ff ff ff 00 d4 |........|........|
|00000e80| 00 d4 00 14 00 3c 00 00 | 01 1d 00 00 00 00 00 00 |.....<..|........|
|00000e90| 00 00 00 00 00 00 00 00 | 00 00 00 00 00 00 00 02 |........|........|
|00000ea0| 0a 14 01 08 0a 51 05 a9 | 00 01 81 81 00 14 00 0a |.....Q..|........|
|00000eb0| 00 00 00 00 00 03 00 01 | 00 01 00 09 53 49 47 4e |........|....SIGN|
|00000ec0| 41 54 55 52 45 1a 00 00 | 00 16 00 01 00 00 00 00 |ATURE...|........|
|00000ed0| 00 0c 00 09 00 14 00 00 | 00 0a 00 00 00 00 00 00 |........|........|
|00000ee0| 00 07 00 00 00 62 0a 84 | 00 6c 0a d8 03 01 00 01 |.....b..|.l......|
|00000ef0| 00 00 ff ff ff ff ff ff | ff ff 00 01 00 00 00 00 |........|........|
|00000f00| 00 00 00 02 0a 84 00 6c | 0a d8 03 01 00 00 00 00 |.......l|........|
|00000f10| 00 14 00 0e 00 03 00 00 | 00 01 00 01 00 01 00 0e |........|........|
|00000f20| 42 45 4e 45 46 49 54 53 | 20 4f 4e 4c 59 3a 00 00 |BENEFITS| ONLY:..|
|00000f30| 00 16 00 01 00 00 00 00 | 00 0f 00 0c 00 14 03 00 |........|........|
|00000f40| 00 0e 00 00 00 00 00 00 | 00 01 00 00 00 ac 0a d4 |........|........|
|00000f50| 00 e3 0b 58 03 c7 00 01 | 00 00 00 00 00 15 00 00 |...X....|........|
|00000f60| 00 0c 00 00 00 03 00 02 | 00 0a 00 01 00 05 00 00 |........|........|
|00000f70| 00 00 00 04 00 01 00 00 | 00 00 00 00 00 00 00 00 |........|........|
|00000f80| 00 00 00 00 00 00 00 00 | 00 03 00 00 ff ff ff ff |........|........|
|00000f90| ff ff ff ff 01 26 01 26 | 00 3c 00 3c 00 00 01 1e |.....&.&|.<.<....|
|00000fa0| 00 00 00 00 00 00 00 00 | 00 00 00 00 00 00 00 00 |........|........|
|00000fb0| 00 00 00 00 00 02 0b 1c | 00 e3 0b 59 03 c8 00 01 |........|...Y....|
|00000fc0| 81 81 00 14 00 0a 00 00 | 00 00 00 03 00 01 00 01 |........|........|
|00000fd0| 00 0d 41 44 4d 49 4e 49 | 53 54 52 41 54 4f 52 70 |..ADMINI|STRATORp|
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|00000ff0| 00 00 00 0a 00 00 00 00 | 00 00 00 01 00 00 00 ac |........|........|
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|00001010| 00 00 00 0c 00 00 00 03 | 00 02 00 00 00 01 00 05 |........|........|
|00001020| 00 00 00 00 00 04 00 01 | 00 00 00 00 00 00 00 00 |........|........|
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|00001070| 00 01 81 81 00 14 00 0a | 00 00 00 00 00 03 00 01 |........|........|
|00001080| 00 01 00 0d 44 41 54 45 | 20 41 50 50 52 4f 56 45 |....DATE| APPROVE|
|00001090| 44 14 00 00 00 16 00 01 | 00 00 00 00 00 0c 00 09 |D.......|........|
|000010a0| 00 14 00 00 00 0a 00 00 | 00 00 00 00 00 01 00 00 |........|........|
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|000010d0| 00 05 00 00 00 00 00 04 | 00 01 00 00 00 00 00 00 |........|........|
|000010e0| 00 00 00 00 00 00 00 00 | 00 00 00 00 00 03 00 00 |........|........|
|000010f0| ff ff ff ff ff ff ff ff | 01 26 01 26 00 3c 00 3c |........|.&.&.<.<|
|00001100| 00 00 01 20 00 00 00 00 | 00 00 00 00 00 00 00 00 |... ....|........|
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|00001120| 08 eb 00 01 81 81 00 14 | 00 0a 00 00 00 00 00 03 |........|........|
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|00001150| 00 14 00 00 00 0a 00 00 | 00 00 00 00 00 07 00 00 |........|........|
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|000012c0| 6e 73 75 72 61 6e 63 65 | 20 63 61 72 72 69 65 72 |nsurance| carrier|
|000012d0| 73 2e 20 20 46 6f 72 20 | 61 6c 6c 20 20 6f 74 68 |s.  For |all  oth|
|000012e0| 65 72 20 68 65 61 6c 74 | 68 20 63 61 72 65 20 65 |er healt|h care e|
|000012f0| 78 70 65 6e 73 65 73 2c | 20 61 74 74 61 63 68 20 |xpenses,| attach |
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|00001410| 00 01 00 00 00 00 00 00 | 00 02 08 28 00 e2 09 94 |........|...(....|
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|00001430| 00 01 00 06 01 96 45 4d | 50 4c 4f 59 45 45 20 41 |......EM|PLOYEE A|
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|00001510| 20 20 49 20 66 75 72 74 | 68 65 72 20 63 65 72 74 |  I furt|her cert|
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|00001570| 2e 20 20 49 20 75 6e 64 | 65 72 73 74 61 6e 64 20 |.  I und|erstand |
|00001580| 74 68 61 74 20 72 65 69 | 6d 62 75 72 73 65 64 20 |that rei|mbursed |
|00001590| 65 78 70 65 6e 73 65 73 | 20 63 61 6e 6e 6f 74 20 |expenses| cannot |
|000015a0| 62 65 20 63 6c 61 69 6d | 65 64 20 6f 6e 20 6d 79 |be claim|ed on my|
|000015b0| 20 70 65 72 73 6f 6e 61 | 6c 20 69 6e 63 6f 6d 65 | persona|l income|
|000015c0| 20 74 61 78 20 72 65 74 | 75 72 6e 2e 00 00 00 3e | tax ret|urn....>|
|000015d0| 00 03 00 00 00 00 00 0f | 00 0c 00 14 01 00 00 0e |........|........|
|000015e0| 00 00 00 00 00 00 00 00 | 00 17 00 0c 00 09 00 14 |........|........|
|000015f0| 01 00 00 0c 00 00 00 00 | 00 00 00 00 00 18 00 0c |........|........|
|00001600| 00 09 00 14 00 00 00 0c | 00 00 00 00 00 00 00 07 |........|........|
|00001610| 00 00 00 f4 07 20 00 af | 07 98 06 2b 00 01 00 00 |..... ..|...+....|
|00001620| ff ff ff ff ff ff ff ff | 00 01 00 00 00 00 00 00 |........|........|
|00001630| 00 02 07 20 00 af 07 98 | 06 2b 00 00 00 00 ff 00 |... ....|.+......|
|00001640| 00 0c ff 00 00 00 00 01 | 00 01 00 02 00 77 43 6f |........|.....wCo|
|00001650| 64 65 3a 20 20 44 20 3d | 20 44 65 6e 74 61 6c 09 |de:  D =| Dental.|
|00001660| 09 09 09 09 09 09 09 09 | 09 20 56 20 3d 20 56 69 |........|. V = Vi|
|00001670| 73 69 6f 6e 09 09 09 09 | 09 09 20 20 20 50 44 20 |sion....|..   PD |
|00001680| 3d 20 50 72 65 73 63 72 | 69 70 74 69 6f 6e 20 44 |= Prescr|iption D|
|00001690| 72 75 67 73 0d 20 20 20 | 20 20 20 20 20 20 20 20 |rugs.   |        |
|000016a0| 20 4d 20 3d 20 4d 65 64 | 69 63 61 6c 20 20 20 20 | M = Med|ical    |
|000016b0| 20 20 20 20 20 50 59 20 | 3d 20 50 73 79 63 68 69 |     PY |= Psychi|
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|000016d0| 00 0c 00 09 00 14 01 00 | 00 0c 00 00 00 00 00 00 |........|........|
|000016e0| 00 00 00 1b 00 0e 00 0a | 00 15 00 00 00 0c 00 00 |........|........|
|000016f0| 00 00 00 00 00 00 00 1c | 00 0c 00 09 00 14 01 00 |........|........|
|00001700| 00 0c 00 00 00 00 00 00 | 00 01 00 00 00 b8 07 04 |........|........|
|00001710| 06 4c 07 94 08 fc 00 01 | 00 00 00 00 00 15 00 00 |.L......|........|
|00001720| 00 0c 00 00 00 02 00 02 | 00 85 00 01 00 03 00 00 |........|........|
|00001730| 00 00 00 03 00 01 ff ff | ff ff ff ff ff ff 00 00 |........|........|
|00001740| 00 00 00 00 00 00 00 00 | 00 03 00 00 ff ff ff ff |........|........|
|00001750| ff ff ff ff 01 58 01 58 | 00 3c 00 3c 00 00 01 21 |.....X.X|.<.<...!|
|00001760| 00 00 00 00 00 00 00 00 | 00 00 00 00 00 00 00 00 |........|........|
|00001770| 00 00 00 00 00 02 07 05 | 06 4d 07 40 08 fc 01 01 |........|.M.@....|
|00001780| 00 01 00 14 00 0a 00 80 | 00 00 00 01 00 02 00 01 |........|........|
|00001790| 00 19 54 4f 54 41 4c 20 | 52 45 49 4d 42 55 52 53 |..TOTAL |REIMBURS|
|000017a0| 41 42 4c 45 20 41 4d 4f | 55 4e 54 32 00 00 00 16 |ABLE AMO|UNT2....|
|000017b0| 00 01 00 00 00 00 00 0c | 00 09 00 14 00 00 00 0a |........|........|
|000017c0| 00 00 00 00 00 00 00 08 | 00 00 03 de 04 c6 00 91 |........|........|
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|00001800| 00 40 00 00 00 48 00 00 | 00 00 01 22 00 00 00 04 |.@...H..|..."....|
|00001810| 00 50 ff ff ff ff ff ff | ff ff ff ff ff ff ff ff |.P......|........|
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|00001830| 00 0b 00 01 07 22 00 00 | 00 00 00 00 00 00 00 00 |....."..|........|
|00001840| 00 00 00 00 00 00 00 00 | 00 00 00 00 00 00 00 00 |........|........|
|00001850| 00 4a 00 02 04 c7 00 92 | 05 16 08 fc 01 01 01 01 |.J......|........|
|00001860| 00 14 00 0e 00 01 00 00 | 00 01 00 03 00 01 00 11 |........|........|
|00001870| 43 4c 41 49 4d 20 49 4e | 46 4f 52 4d 41 54 49 4f |CLAIM IN|FORMATIO|
|00001880| 4e 1e 00 00 00 16 00 01 | 00 00 00 00 00 0f 00 0c |N.......|........|
|00001890| 00 14 01 00 00 0e 00 00 | 00 00 00 00 00 04 03 60 |........|.......`|
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|00001950| 00 01 00 00 00 00 00 0c | 00 09 00 14 00 00 00 0a |........|........|
|00001960| 00 00 00 00 00 00 01 c8 | 00 1a a8 1c 00 00 00 00 |........|........|
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|000019b0| 00 00 00 00 00 03 00 02 | ff ff ff ff ff ff ff ff |........|........|
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|000019d0| 00 00 00 00 00 00 00 00 | 00 00 00 00 00 00 00 00 |........|........|
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|000019f0| 00 0a 00 80 00 00 00 03 | 00 03 00 01 00 10 44 41 |........|......DA|
|00001a00| 54 45 53 20 4f 46 20 53 | 45 52 56 49 43 45 00 00 |TES OF S|ERVICE..|
|00001a10| 00 16 00 01 00 00 00 00 | 00 0c 00 09 00 14 00 00 |........|........|
|00001a20| 00 0a 00 00 00 00 00 00 | 00 94 00 13 d6 b2 00 00 |........|........|
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|00001a90| 00 00 00 00 00 00 00 00 | 00 00 00 00 00 00 00 00 |........|........|
|00001aa0| 00 00 00 02 05 17 05 ba | 05 56 06 4d 01 01 01 01 |........|.V.M....|
|00001ab0| 00 14 00 0a 00 80 00 00 | 00 03 00 03 00 01 00 04 |........|........|
|00001ac0| 43 4f 44 45 00 00 00 16 | 00 01 00 00 00 00 00 0c |CODE....|........|
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|00001b60| 08 fc 01 01 01 01 00 14 | 00 0a 00 80 00 00 00 03 |........|........|
|00001b70| 00 03 00 01 00 19 41 4d | 54 20 4e 4f 54 20 50 41 |......AM|T NOT PA|
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|00001b90| 00 00 00 16 00 01 00 00 | 00 00 00 0c 00 09 00 14 |........|........|
|00001ba0| 00 00 00 0a 00 00 00 00 | 00 00 00 02 00 00 00 22 |........|......."|
|00001bb0| 05 17 03 f1 05 55 03 f1 | 00 01 00 00 00 03 00 00 |.....U..|........|
|00001bc0| 00 00 00 00 00 00 00 00 | 00 00 00 00 00 00 00 00 |........|........|
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|00001be0| 00 01 00 00 00 03 00 00 | 00 00 00 00 00 00 00 00 |........|........|
|00001bf0| 00 00 00 00 00 00 00 00 | 00 00 00 02 00 00 00 22 |........|......."|
|00001c00| 05 18 06 4d 05 56 06 4d | 00 01 00 00 00 03 00 00 |...M.V.M|........|
|00001c10| 00 00 00 00 00 00 00 00 | 00 00 00 00 00 00 00 00 |........|........|
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|00001c90| 00 00 00 16 00 01 00 00 | 00 00 00 0c 00 09 00 14 |........|........|
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|00001ce0| 00 00 00 01 00 01 00 01 | 00 1b 42 65 6e 65 66 69 |........|..Benefi|
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|00001d20| 00 00 00 00 00 03 00 00 | 00 34 00 10 00 10 0c 50 |........|.4.....P|
|00001d30| 09 80 00 01 00 00 00 03 | 00 01 ff ff ff ff ff ff |........|........|
|00001d40| ff ff 00 00 00 00 00 00 | 00 00 00 00 00 01 00 28 |........|.......(|
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|00001d90| 00 0c 00 00 00 00 00 03 | 00 03 00 01 00 4e 50 4c |........|.....NPL|
|00001da0| 45 41 53 45 20 55 53 45 | 20 54 48 45 20 54 41 42 |EASE USE| THE TAB|
|00001db0| 20 4b 45 59 20 54 4f 20 | 4d 4f 56 45 20 46 52 4f | KEY TO |MOVE FRO|
|00001dc0| 4d 20 20 46 49 45 4c 44 | 20 54 4f 20 46 49 45 4c |M  FIELD| TO FIEL|
|00001dd0| 44 20 57 48 45 4e 20 46 | 49 4c 4c 49 4e 47 20 4f |D WHEN F|ILLING O|
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|00001e30| 06 73 00 00 00 00 00 14 | 00 00 00 01 00 00 00 03 |.s......|........|
|00001e40| 00 03 00 02 00 26 43 55 | 53 54 4f 4d 20 43 4f 56 |.....&CU|STOM COV|
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|00001e60| 45 20 43 4c 41 49 4d 20 | 46 4f 52 4d 00 00 00 2a |E CLAIM |FORM...*|
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|00001e80| 00 00 00 00 00 00 00 00 | 00 10 00 0c 00 09 00 14 |........|........|
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|00001eb0| ff ff ff ff 00 01 00 00 | 00 00 00 00 00 02 02 2c |........|.......,|
|00001ec0| 00 ef 03 43 05 16 00 00 | 00 00 00 15 00 0c 00 01 |...C....|........|
|00001ed0| 00 00 00 03 00 03 00 05 | 00 5f 46 4f 52 20 48 45 |........|._FOR HE|
|00001ee0| 4c 50 20 43 41 4c 4c 20 | 54 48 45 20 42 45 4e 45 |LP CALL |THE BENE|
|00001ef0| 46 49 54 53 20 48 45 4c | 50 20 44 45 53 4b 3a 0d |FITS HEL|P DESK:.|
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+--------+-------------------------+-------------------------+--------+--------+