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EMPLOYER NAME: KITTITAS COUNTY <br />The below signed applicant agrees that if the requested insurance is acceptable to WCIF under its current rules and practices <br />and is legally permissible, a policy will be issued in the policy language customarily used by WCIF and will be effective on the <br />date determined by WCIF. <br />The below signed applicant acknowledges it is a crime to knowingly provide false, incomplete, or misleading information to an <br />insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines and denial of insurance <br />benefits. <br />Name & Title: Obie O'Brien, Chairman, BOCC <br />Authorized Signature: <br />Remarks: - <br />Date: 10/11/16 <br />Premera Blue Cross <br />7001 220th St SW <br />Mountlake Terrace, WA 98403 <br />Plan number unique to employer. <br />Contact WCIF at (800) 344-8570 to obtain. <br />Group Health Options, Inc. <br />320 Westlake Avenue N Suite 100 <br />Seattle, WA 98109-5233 <br />Plan number unique to employer. <br />Contact WCIF at (800) 344-8570 to obtain. <br />Group Health Cooperative <br />320 Westlake Avenue N Suite 100 <br />Seattle, WA 98109-5233 <br />Plan number unique to employer. <br />Contact WCIF at (800) 344-8570 to obtain. <br />Standard Insurance Company <br />1100 SW 6th Avenue <br />Portland, OR 97204 <br />645273 <br />Delta Dental of Washington <br />9706 4th Avenue NE <br />Seattle, WA 98115 <br />00497 00498 00500 <br />00501 00502 00478 <br />Willamette Dental of Washington Inc <br />6950 NE Campus Way <br />Hillsboro, OR 97124 <br />WA204 <br />VSP Vision Care, Inc. <br />3333 Quality Drive <br />Rancho Cordova, CA 95670 <br />30029829 <br />Magellan Health, Inc. <br />55 Nod Road <br />Avon, CT 06001 <br />2017GMA2 Page 8 of 9 (092116JM) <br />