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Get Sglv 8286a July 2006

S Information (To be completed by member. It is not necessary to complete this section if you re declining coverage.) Last name First name Middle name Social Security Number Suffix (Jr., Sr., etc.) Date of Birth (dd-mmm-yyyy e.g. 24-AUG-1965) Premiums for Spousal Coverage Spouse's age: Monthly rate per $10,000 Monthly cost for $100,000 coverage Under 35 35-39 40-44 45-49 50-54 55-59 60 & older $.55 $.70 $.90 $1.40 $2.70 $4.00 $5.20 $5.50 $7.00 $9.00 $14.00 $27.00 $40.00 $52.00.

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