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you have a spouse whoAWAB2552552550000000000000000000000010Arial80001117974574000000000200242008819200000000000000000000000000000000000000000000000200242008819200010000000000000000000000000000000000000000000000000010000000000000000200242008819200000000000000000000000000000000000000000002002420088193is currently employed?AWAC2552552550000000000000000000000010Arial80001117974574000000000200242008819300000000000000000000000000000000000000000000000200242008819300010000000000000000000000000000000000000000000000000010000000000000000200242008819300000000000000000000000000000000000000000002002420088194No-Never 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Retirement:AWAG2122082000001010000000000000184215041000Arial800000179745740100000002002420088196000000000000000000000000000000000000000000000002002420088196012//5E001000000001000000000000000000000000000000000000016777216010000000000000000200242008819600000000000000000000000000000000000000000002002420088197Yes-EmployedMi4gIERvIHlvdSBoYXZlIGEgc3BvdXNlIHdobyBpcyBjdXJyZW50bHkgZW1wbG95ZWQ/AWAI2122082000001010010000000000184215041000Arial80000017974574010000000200242008819700000000000000000000000000000000000000000000000200242008819700000100000000100000000100000000000000000000000000000010000000000000000200242008819700000000000000000000000000000000000000000002002420088197120024200882021200242008819722002420088198120024200881973200242008819912002420088197120024200882021200242008819722002420088198120024200881973200242008819912002420088198Name of spouse's employer:AWAJ2122082000001010000000000000184215041000Arial800000179745740100000002002420088198000000000000000000000000000000000000000000000002002420088198014//5OAGEAbQBlACAAbwBmACAAcwBwAG8AdQBzAGUAJwBzACAAZQBtAHAAbABvAHkAZQByAC4A00100000000100000000000000000000000000000000000000010000000000000000200242008819800000000000000000000000000000000000000000002002420088199Address of spouse's employer:AWAK2122082000001010000000000000184215041000Arial800000179745740100000002002420088199000000000000000000000000000000000000000000000002002420088199014//5BAGQAZAByAGUAcwBzACAAbwBmACAAcwBwAG8AdQBzAGUAJwBzACAAZQBtAHAAbABvAHkAZQBy AC4A00100000000100000000000000000000000000000000000000010000000000000000200242008819900000000000000000000000000000000000000000002002420088200No-Never 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you have group health planAXAB2552552550000000000000000000000010Arial80001117974574000000000200242008820300000000000000000000000000000000000000000000000200242008820300010000000000000000000000000000000000000000000000000010000000000000000200242008820300000000000000000000000000000000000000000002002420088204(GHP) coverage based on yourAXAC2552552550000000000000000000000010Arial80001117974574000000000200242008820400000000000000000000000000000000000000000000000200242008820400010000000000000000000000000000000000000000000000000010000000000000000200242008820400000000000000000000000000000000000000000002002420088205own or a spouse's 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BothMy4gIERvIHlvdSBoYXZlIGdyb3VwIGhlYWx0aCBwbGFuIChHSFApIGNvdmVyYWdlIGJhc2VkIG9u IHlvdXIgb3duIG9yIGEgc3BvdXNlJ3MgY3VycmVudCBlbXBsb3ltZW50Pw==AXAF2122082000001010010000000000184215041000Arial8000001797457401000000020024200882070000000000000000000000000000000000000000000000020024200882070000010000000010010000010000000000000000000000000000001000000000000000020024200882070000000000000000000000000000000000000000000200242008820712002420088210120024200882071200242008821012002420088208Yes. Self.My4gIERvIHlvdSBoYXZlIGdyb3VwIGhlYWx0aCBwbGFuIChHSFApIGNvdmVyYWdlIGJhc2VkIG9u IHlvdXIgb3duIG9yIGEgc3BvdXNlJ3MgY3VycmVudCBlbXBsb3ltZW50Pw==AXAG2122082000001010010000000000184215041000Arial8000001797457401000000020024200882080000000000000000000000000000000000000000000000020024200882080000010000000010010000010000000000000000000000000000001000000000000000020024200882080000000000000000000000000000000000000000000200242008820812002420088211120024200882081200242008821112002420088214Yes. SpouseMy4gIERvIHlvdSBoYXZlIGdyb3VwIGhlYWx0aCBwbGFuIChHSFApIGNvdmVyYWdlIGJhc2VkIG9u IHlvdXIgb3duIG9yIGEgc3BvdXNlJ3MgY3VycmVudCBlbXBsb3ltZW50Pw==AXAH2122082000001010010000000000184215041000Arial8000001797457401000000020024200882140000000000000000000000000000000000000000000000020024200882140000010000000010010000010000000000000000000000000000001000000000000000020024200882140000000000000000000000000000000000000000000200242008821412002420088213120024200882141200242008821312002420088209No.My4gIERvIHlvdSBoYXZlIGdyb3VwIGhlYWx0aCBwbGFuIChHSFApIGNvdmVyYWdlIGJhc2VkIG9u IHlvdXIgb3duIG9yIGEgc3BvdXNlJ3MgY3VycmVudCBlbXBsb3ltZW50Pw==AXAI2122082000001010010000000000184215041000Arial8000001797457401000000020024200882090000000000000000000000000000000000000000000000020024200882090000010000000010010000010000000000000000000000000000001000000000000000020024200882090000000000000000000000000000000000000000000200242008820912002420088212120024200882091200242008821212002420088210Yes. Both.AXBB02552550000010000000000000184215040000Arial80000017974574010000000200242008821000000000000000000000000000000000000000000000000200242008821000000000000000100000000000000000000000000000000000000010000000000000000200242008821000000000000000000000000000000000000000000002002420088211Yes. Self.AXBC02552550000010000000000000184215040000Arial80000017974574010000000200242008821100000000000000000000000000000000000000000000000200242008821100000000000000100000000000000000000000000000000000000010000000000000000200242008821100000000000000000000000000000000000000000002002420088213Yes. Spouse.AXBD02552550000010000000000000184215040000Arial80000017974574010000000200242008821300000000000000000000000000000000000000000000000200242008821300000000000000100000000000000000000000000000000000000010000000000000000200242008821300000000000000000000000000000000000000000002002420088212No.AXBE02552550000010000000000000184215040000Arial80000017974574010000000200242008821200000000000000000000000000000000000000000000000200242008821200000000000000100000000000000000000000000000000000000010000000000000000200242008821200000000000000000000000000000000000000000002002420088217AYAA128128642552552550000000000000000000001Arial1400501018421504000000000200242008821700000000000000000000000000000000000000000000000200242008821700010000000000000000000000000000000000000000000000000010000000000000000200242008821700000000000000000000000000000000000000000002002420088215Are you covered under the GHPAYAB2552552550000000000000000000000010Arial80001117974574000000000200242008821500000000000000000000000000000000000000000000000200242008821500010000000000000000000000000000000000000000000000000010000000000000000200242008821500000000000000000000000000000000000000000002002420088216of a family member other thanAYAC2552552550000000000000000000000010Arial80001117974574000000000200242008821600000000000000000000000000000000000000000000000200242008821600010000000000000000000000000000000000000000000000000010000000000000000200242008821600000000000000000000000000000000000000000002002420088219your spouse?AYAD2552552550000000000000000000000010Arial80001117974574000000000200242008821900000000000000000000000000000000000000000000000200242008821900010000000000000000000000000000000000000000000000000010000000000000000200242008821900000000000000000000000000000000000000000002002420088224No.NC4gIEFyZSB5b3UgY292ZXJlZCB1bmRlciB0aGUgR0hQIG9mIGEgZmFtaWx5IG1lbWJlciBvdGhl 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20024AR20013416501Arial1010