| Document Date: 2014-10-03 19:33:35
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Company Other Insurance Company / United HealthCare Services Inc. / / Currency USD / / IndustryTerm health insurance coverage / health insurance administration / legal services / medical information services / insurance / tobacco products / / MedicalCondition ADHD / No Colon Leukemia Lymphoma Liver Lung Melanoma Testicular Brain Ovarian Prostate Other Cancer_ Non-Malignant Tumor / injury / Brain/Nervous Yes No Alzheimer’s Cerebral Palsy Migraines Parkinson’s Disease Head Injury Cyst / Urinary/Kidney Yes No Kidney Stones Renal Failure / Lupus Immuno Deficiency Kidney Disorders Bladder Disorders Polycystic Kidney Disease Other________________________________________ Stem Cell Disability Prostate Disorder Knee Disorder Transplant Complications Congenital Disorder / alcohol abuse / illness / / MedicalTreatment psychotherapy / / Organization Medicare / / Person Injury Cyst / / / Position Disease Head / Physician / plan administrator / independent contractor / representative / / Product UHCEW646682-000 / / ProvinceOrState Wisconsin / /
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All Savers Employee Enrollment – Alternate Funding Please send correspondence to P.O. Box 19032, Green Bay, WI • Please fill out the entire enrollment form to avoid processing delay. Plea