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� . � • • <br /> COMPLETED BY HCSC <br /> Booklet Request: <br /> Number of Booklets Ship booklets to: <br /> Attn: <br /> Mail Health Care Plan to: ❑ Group � District � <br /> Underwriting Oniy <br /> Date BPA approved by Underwriting . � <br /> Signature of Underwriting approving <br /> � <br /> � - � <br /> � <br /> ) <br /> � <br /> :r. +�i.r H�;c�;Rav.5l88 <br /> Page 4 of 4 <br />