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UnitedHealthcare Insurance Company, as <br />signed by its authorized representative <br />Signature: <br />Print Name: <br />Title: <br />Date: <br />Kittitas County, as signed by its authorized <br />representative <br />Signature: ", ✓�.zy.r� <br />Print Name: CLA y Nt y&g S <br />Title: SHE'R1 Fr <br />Date: 6 - W - x6 <br />TIN: � f - (r b % 3 L/l <br />UnitedHealthcare of Washington, Inc., as Kittitas County, as signed by its authorized <br />signed by its authorized representative representative <br />Signature: Signature: <br />Print Name: Print Name: G ey4 jt !�c R S <br />Title: Title: SHEf{1FF _ <br />Date: Date: G -S D - AL <br />TIN: I [evDi 3 Yg <br />UnitedHealthcare of Oregon, Inc., as signed Kittitas County, as signed by its authorized <br />by its authorized representative representative <br />Signature: Signature: <br />Print Name: <br />Title: <br />Date: <br />Gen.Amd.SMGA. BH. WA.0625 <br />7 <br />Print Name: G,t.47 ,vr FRS <br />Title: $Reg)r-F <br />Date: 6 • 3O- X, �/ <br />TIN: �� ( - L Db I l <br />- 2 - UnitedHealtkcare <br />Confidential and Proprietary <br />