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<br />US BENEFITS, INC" <br /> <br />LARGE CLAIM DISCLOSURE <br /> <br />1. To the best of our knowledge there are no employees or dependents with <br />current serious medical conditions with the following exceptions: <br /> <br />Individual <br /> <br />Date Amount <br />Disabled Paid <br /> <br />Diaqnosis <br /> <br />proqnosis <br /> <br />1. <br /> <br />2. <br /> <br />3 . <br /> <br />2. Please provide the following information for any employee or dependent <br />who has had claims in excess of $15,000 (or 50% of specific, if less) <br />during the last two years. <br /> <br />Individual <br /> <br />Emo/Deo <br /> <br />Date Amount <br />Disabled Paid <br /> <br />Diaqnosis <br /> <br />status <br /> <br />1. <br /> <br />2. <br /> <br />3. <br /> <br />4. <br /> <br />Third Party Admn.: <br /> <br />HEALTHCARE BENEFITS, INC. <br /> <br />By <br /> <br />Date <br /> <br />Name of company: <br /> <br />CITY OF PARIS <br /> <br />Signed By: <br />Title <br /> <br />Date <br /> <br />Please use the back of this form if additional space is required. <br /> <br />3/93 <br />