<p> NEW GROUP Anthem Senior Advantage Employer Group Quote Sheet Proposed Effective Date / 01 /04 Agent: Account Executive: Martiese Head Agent’s Phone # 216-573-4663 Agents’s Mail Code VS1-621 E-mail: [email protected]</p><p>The effective date of coverage is the first day of a month. The month may be up to 3 months into the future. The effective date can never be prior to the signature date on the Enrollment Form. Group Name</p><p>Address City State Zip</p><p>Retiree Benefits Decision Maker</p><p>Billing Contact</p><p>Broker</p><p>Is Anthem the Exclusive Medicare + Choice Program Offered? Yes No</p><p>If Anthem Medicare Supplemental is offered which Plan(s) A – J?</p><p># of Eligibles</p><p>Check all delivery systems in which retirees reside and provide # of eligibles in each Health Service Area by County:</p><p> Akron  Cincinnati  Columbus  Cleveland  Dayton  Warren / Youngstown Medina Brown Franklin Cuyahoga Butler Columbiana Portage Clermont Madison Geauga Darke** Mahoning Summit Hamilton Union Lake Greene Trumbull Lorain Miami Stark Montgomery Preble Shelby Warren</p><p> Louisville  Northern Kentucky Jefferson Boone **only certain zip Oldham Kenton codes eligible Campbell</p><p>Who is the commercial carrier? Who is the commercial agent (if applicable)? Number of commercial actives Electronic Reconciliation: Yes No (over) NEW GROUP Comments/Special Instructions:</p><p>Please quote the following Ohio Choice Select Custom options: Kentucky Choice Select Custom</p><p>Send copy of quote to: ASA Representative Commercial Group Rep</p><p>Sales Agent Martiese Head Date: Signature: Retiree Benefits Date: Decision Maker Signature:</p><p>FOR INTERNAL USE ONLY Approved: Yes No Rate(s): Ohio Kentucky Comments Choice Select Custom</p><p>Date: Signature:</p><p>(over)</p>