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FOR ADMINISTRATOR USE ONLY: <br />Approved by: <br />❑ Premera Base Demographic Risk Level: <br />❑ Group Health Base Demographic Risk Level: <br />Special Notes: <br />FOR CARRIER USE ONLY: <br />Date: <br />❑ Producer Commissions Attached <br />❑ Proof of Funding Received <br />❑ Bundled (Base LTD) Medical Only <br />❑ Bundled (EAP) Medical Only <br />2017GMA2 Page 9 of 9 (092116JM) <br />