%PDF-1.7
%
1 0 obj
<>
endobj
2 0 obj
[21 0 R 33 0 R 23 0 R 27 0 R 44 0 R 48 0 R 34 0 R 31 0 R 43 0 R 46 0 R 47 0 R 49 0 R 54 0 R 56 0 R 57 0 R 59 0 R 68 0 R 72 0 R 75 0 R 78 0 R 81 0 R 84 0 R 86 0 R 88 0 R 91 0 R 94 0 R 97 0 R]
endobj
4 0 obj
<>
endobj
5 0 obj
[119 0 R 129 0 R 124 0 R 120 0 R 118 0 R 144 0 R 148 0 R 140 0 R 132 0 R 154 0 R 158 0 R 146 0 R 162 0 R 153 0 R 141 0 R 160 0 R 164 0 R 157 0 R 163 0 R 167 0 R 169 0 R 171 0 R 176 0 R 179 0 R]
endobj
7 0 obj
<>
endobj
8 0 obj
[198 0 R 213 0 R 199 0 R 203 0 R 200 0 R 214 0 R 225 0 R 229 0 R 215 0 R 211 0 R 226 0 R 227 0 R 237 0 R 240 0 R 230 0 R 221 0 R 238 0 R 239 0 R]
endobj
10 0 obj
<>
endobj
11 0 obj
[264 0 R 272 0 R 274 0 R 267 0 R 265 0 R 280 0 R 283 0 R 281 0 R 285 0 R 289 0 R 290 0 R 293 0 R 295 0 R 297 0 R 299 0 R 301 0 R 303 0 R 305 0 R 307 0 R 309 0 R 311 0 R 313 0 R 315 0 R 317 0 R 319 0 R 321 0 R 323 0 R 325 0 R 327 0 R 329 0 R 331 0 R 333 0 R 335 0 R 337 0 R 339 0 R 341 0 R 343 0 R 345 0 R 347 0 R 349 0 R 351 0 R 353 0 R 355 0 R 357 0 R 359 0 R 361 0 R 363 0 R 365 0 R 367 0 R 369 0 R 371 0 R 373 0 R 375 0 R 377 0 R 379 0 R 381 0 R 383 0 R 385 0 R 387 0 R 389 0 R 391 0 R 393 0 R 395 0 R 397 0 R 399 0 R 401 0 R 407 0 R 411 0 R 404 0 R 396 0 R 408 0 R 409 0 R 410 0 R]
endobj
13 0 obj
<>
endobj
14 0 obj
[480 0 R 477 0 R 483 0 R 487 0 R 478 0 R 494 0 R 502 0 R 506 0 R 496 0 R 492 0 R 503 0 R 504 0 R 505 0 R]
endobj
16 0 obj
<>
endobj
17 0 obj
[523 0 R 527 0 R 525 0 R 524 0 R 528 0 R 537 0 R 541 0 R 534 0 R 538 0 R 542 0 R 546 0 R 545 0 R 548 0 R 551 0 R 552 0 R 5263 0 R]
endobj
19 0 obj
<>
stream
application/postscript
Print
Susan Leavy
2016-02-10T10:12:37-05:00
2016-02-10T10:12:37-05:00
2016-02-10T10:12:37-05:00
Adobe Illustrator CC 2015 (Macintosh)
xmp.iid:b210a3d3-2a0c-408d-bd14-558ff95e0109
xmp.did:b210a3d3-2a0c-408d-bd14-558ff95e0109
uuid:5D20892493BFDB11914A8590D31508C8
proof:pdf
xmp.iid:ef19722f-54d9-466b-886c-e664ea0f3e1a
xmp.did:ef19722f-54d9-466b-886c-e664ea0f3e1a
uuid:5D20892493BFDB11914A8590D31508C8
proof:pdf
saved
xmp.iid:ef19722f-54d9-466b-886c-e664ea0f3e1a
2016-02-08T14:28:08-05:00
Adobe Illustrator CC 2015 (Macintosh)
/
converted
from application/postscript to application/vnd.adobe.illustrator
saved
xmp.iid:b210a3d3-2a0c-408d-bd14-558ff95e0109
2016-02-10T10:12:37-05:00
Adobe Illustrator CC 2015 (Macintosh)
/
Print
False
False
1
4.750000
1.500000
Inches
Black
Default Swatch Group
0
White
CMYK
PROCESS
0.000000
0.000000
0.000000
0.000000
C=0 M=0 Y=0 K=100
CMYK
PROCESS
0.000000
0.000000
0.000000
100.000000
Adobe PDF library 10.01
endstream
endobj
20 0 obj
<>
endobj
21 0 obj
<>
/MK 92 0 R
/FT /Tx
/BS <>
/Rect [39.6642 614.5090 294.7820 637.1860]
/Q 0
/T (Claim Form Entry 11)
/Type /Annot
/P 1 0 R
/F 4
/Subtype /Widget
/DA (/TiRo 10 Tf 0 g)
/Ff 8388610
>>
endobj
22 0 obj
<>
/ExtGState <>
>>
/Subtype /Form
/Length 76
/Filter /FlateDecode
/Matrix [1.0000 0.0000 0.0000 1.0000 0.0000 0.0000]
>>
stream
Hw6PH.V0г4PR89K(^e`dgfn`djghhrqT(8:+p }
endstream
endobj
23 0 obj
<>
>>
/MK 79 0 R
/BS <>
/Rect [219.3450 761.2450 228.3490 770.2490]
/Type /Annot
/P 1 0 R
/F 4
/Subtype /Widget
/Parent 570 0 R
/AS /Off
>>
endobj
24 0 obj
<>
/ExtGState <>
>>
/Subtype /Form
/Length 76
/Filter /FlateDecode
/Matrix [1.0000 0.0000 0.0000 1.0000 0.0000 0.0000]
>>
stream
Hw6PH.V0г4PR89K(^e`dgfn`hjgadrqT(8:+p
endstream
endobj
25 0 obj
<>
/ExtGState <>
>>
/Subtype /Form
/Length 276
/Filter /FlateDecode
/Matrix [1.0000 0.0000 0.0000 1.0000 0.0000 0.0000]
>>
stream
H4PJ@S&O=
~JiN&nж\snt#'|>@~e2՟ײ5<7E%QY='^Q+- #Ftzg1
$EY:tRpfJRYЩ$сם
V_0tFTv