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		<title>Annual Survey - Ohio Health Insurance Business</title>
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         <div style="margin-left:315px; margin-top: 10px; border-spacing: 0px; padding: 0px; width: 669px;" class="FrmTable" align="center">
            <div class="FrmTitleBackGrnd" style="font-weight: bold; color: #000000;padding-left:5px;" align="left">
                Annual Report of Ohio Health Insurance Business - <br />Health Plan Benefit Specific Information
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                              href="Instructions/Help.pdf" target="helpwindow">Help</a>
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                <table width="100%" border="0" role="presentation">
                    <tr valign="baseline">
                        <td width="17">
                            <img src="/images/frmBullet.gif" alt=""/></td>
                        <td width="484" height="20" class="FrmInfo">Data for <b>
                            <asp:Label ID="lblCompanyName" runat="server"></asp:Label></b></td>
                    </tr>
                    <tr valign="baseline">
                        <td width="17">
                            <img src="/images/frmBullet.gif" alt=""/></td>
                        <td height="20" class="FrmInfo">NAIC Number:<b>
                            <asp:Label ID="lblNaicNum" runat="server"></asp:Label></b>
                        </td>
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                    <tr valign="baseline">
                        <td width="17">
                            <img src="/images/frmBullet.gif" alt=""></td>
                        <td height="20" class="FrmInfo"><b>INFORMATION RELATED ONLY TO BUSINESS IN OHIO</b></td>
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                    <tr valign="baseline">
                        <td width="14">
                            <img src="/images/frmBullet.gif" alt=""/></td>
                        <td height="20" class="FrmInfo">
                            <b>REPORTING FOR THE PREVIOUS YEAR BEGINS MID-MARCH</b></td>
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                    <tr valign="baseline">
                        <td width="14">
                            <img src="/images/frmBullet.gif" alt=""/></td>
                        <td height="20" class="FrmInfo">
                            <b>CURRENTLY VIEWING FOR THE YEAR ENDING
															<asp:Label ID="lblPeriod" runat="server"></asp:Label></b></td>
                    </tr>
                    <tr>
                        <td class="FrmInfo" height="30" valign="bottom" colspan="2">
                            <b>INSTRUCTIONS:</b>
                        </td>
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                        <td width="17">
                            <img src="/images/frmBullet.gif" alt=""/></td>
                        <td height="20" class="FrmInfo"><b>THIS DATA APPLIES ONLY TO COMPANIES WITH TYPES OF 
														    BUSINESS LISTED UNDER THE SECTIONS TITLED "MEDICAL". </b>
                        </td>
                    </tr>
                    <tr valign="baseline">
                        <td width="17">
                            <img src="/images/frmBullet.gif" alt=""/></td>
                        <td height="20" class="FrmInfo">Provide an estimate of the total number of lives 
													    for all Health Plans (see definition 1) listed under the Medical sections that 
													    are covered for Dental, Prescription Drug, or Vision benefits.
                        </td>
                    </tr>
                    <tr valign="baseline">
                        <td width="17">
                            <img src="/images/frmBullet.gif" alt=""/></td>
                        <td height="20" class="FrmInfo">Do not include lives listed under the Supplemental 
													    Coverage or Supplemental/Specialty Plans sections.
                        </td>
                    </tr>
                    <tr valign="baseline">
                        <td width="17">
                            <img src="/images/frmBullet.gif" alt=""/></td>
                        <td height="20" class="FrmInfo"><b>ALL FIELDS MUST BE COMPLETED. ENTER "0" IF A BENEFIT 
														    LISTED BELOW IS NOT INCLUDED IN ANY HEALTH PLAN OFFERED BY THIS COMPANY.</b>
                        </td>
                    </tr>
                    <tr valign="baseline">
                        <td width="17">
                            <img src="/images/frmBullet.gif" alt=""/></td>
                        <td height="20" class="FrmInfo"><b>SAVE DATA BEFORE LEAVING THIS PAGE. </b>
                        </td>
                    </tr>
                    <tr>
                        <td class="FrmError" colspan="2">
                            <asp:ValidationSummary ID="vsError" runat="server" EnableViewState="False" Width="100%" HeaderText="PLEASE CORRECT THE FOLLOWING ERROR(S):"
                                CssClass="frmError" ShowMessageBox="True"></asp:ValidationSummary>
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                        <td class="FrmError" colspan="2">
                            <asp:Label ID="lblError" runat="server" EnableViewState="False"></asp:Label></td>
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                </table>
            </div>
            <div class="FrmBackGrnd" style="border: 2px solid black; margin: 5px; ">
            <div class="FrmSecHead" style="background-color: #cccccc; height:15px;padding-top:5px;padding-bottom:5px; border-bottom: 2px solid black;">
                Individual - Health Insurance 
            </div>
                 <table cellspacing="2" cellpadding="2" width="100%" border="0" role="presentation">
                           <tr>
                               <td class="FrmFieldTxt"><span class="Required">*</span> Total Number of Lives - 
																						    Dental:&nbsp;</td>
                               <td>
                                   <uc1:wucNumber ID="wucHiIndvDental" runat="server" Size="10" REQUIRED="true" invErrMsg="Individual - Health Insurance -> Total Number of Lives - Dental is not valid."
                                       reqErrMsg="Individual - Health Insurance -> Total Number of Lives - Dental is required."></uc1:wucNumber>
                               </td>
                           </tr>
                           <tr>
                               <td class="FrmFieldTxt"><span class="Required">*</span> Total Number of Lives - 
																						    Prescription Drug:&nbsp;</td>
                               <td>
                                   <uc1:wucNumber ID="wucHiIndvDrug" runat="server" Size="10" REQUIRED="true" invErrMsg="Individual - Health Insurance -> Total Number of Lives - Prescription Drug is not valid."
                                       reqErrMsg="Individual - Health Insurance -> Total Number of Lives - Prescription Drug is required."></uc1:wucNumber>
                               </td>
                           </tr>
                           <tr>
                               <td class="FrmFieldTxt"><span class="Required">*</span> Total Number of Lives - 
																						    Vision:&nbsp;</td>
                               <td>
                                   <uc1:wucNumber ID="wucHiIndvVision" runat="server" Size="10" REQUIRED="true" invErrMsg="Individual - Health Insurance -> Total Number of Lives - Vision is not valid."
                                       reqErrMsg="Individual - Health Insurance -> Total Number of Lives - Vision is required."></uc1:wucNumber>
                               </td>
                           </tr>
                       </table>
            </div>
            <div class="FrmBackGrnd" style="border: 2px solid black; margin: 5px; ">
            <div class="FrmSecHead" style="background-color: #cccccc; height:15px;padding-top:5px;padding-bottom:5px; border-bottom: 2px solid black;">
                Group/Blanket - Health Insurance 
            </div>
                <table cellspacing="2" cellpadding="2" width="100%" border="0" role="presentation">
                    <tr>
                        <td class="FrmFieldTxt"><span class="Required">*</span> Total Number of Lives - 
																						    Dental:&nbsp;</td>
                        <td>
                            <uc1:wucNumber ID="wucHiGroupDental" runat="server" Size="10" REQUIRED="true" invErrMsg="Group/Blanket - Health Insurance -> Total Number of Lives - Dental is not valid."
                                reqErrMsg="Group/Blanket - Health Insurance -> Total Number of Lives - Dental is required."></uc1:wucNumber>
                        </td>
                    </tr>
                    <tr>
                        <td class="FrmFieldTxt"><span class="Required">*</span> Total Number of Lives - 
																						    Prescription Drug:&nbsp;</td>
                        <td>
                            <uc1:wucNumber ID="wucHiGroupDrug" runat="server" Size="10" REQUIRED="true" invErrMsg="Group/Blanket - Health Insurance -> Total Number of Lives - Prescription Drug is not valid."
                                reqErrMsg="Group/Blanket - Health Insurance -> Total Number of Lives - Prescription Drug is required."></uc1:wucNumber>
                        </td>
                    </tr>
                    <tr>
                        <td class="FrmFieldTxt"><span class="Required">*</span> Total Number of Lives - 
																						    Vision:&nbsp;</td>
                        <td>
                            <uc1:wucNumber ID="wucHiGroupVision" runat="server" Size="10" REQUIRED="true" invErrMsg="Group/Blanket - Health Insurance -> Total Number of Lives - Vision is not valid."
                                reqErrMsg="Group/Blanket - Health Insurance -> Total Number of Lives - Vision is required."></uc1:wucNumber>
                        </td>
                    </tr>
                </table>
            </div>
            <div class="FrmBackGrnd" style="border: 2px solid black; margin: 5px; ">
            <div class="FrmSecHead" style="background-color: #cccccc; height:15px;padding-top:5px;padding-bottom:5px; border-bottom: 2px solid black;">
                Individual - Health Insuring Corporation (HMO Products)
            </div>
                 <table cellspacing="2" cellpadding="2" width="100%" border="0" role="presentation">
                     <tr>
                         <td class="FrmFieldTxt"><span class="Required">*</span> Total Number of Lives - 
																						    Dental:&nbsp;</td>
                         <td>
                             <uc1:wucNumber ID="wucHicNgrpDental" runat="server" Size="10" REQUIRED="true" invErrMsg="Non Group - HIC -> Total Number of Lives - Dental is not valid."
                                 reqErrMsg="Non Group - HIC -> Total Number of Lives - Dental is required."></uc1:wucNumber>
                         </td>
                     </tr>
                     <tr>
                         <td class="FrmFieldTxt"><span class="Required">*</span> Total Number of Lives - 
																						    Prescription Drug:&nbsp;</td>
                         <td>
                             <uc1:wucNumber ID="wucHicNgrpDrug" runat="server" Size="10" REQUIRED="true" invErrMsg="Non Group - HIC -> Total Number of Lives - Prescription Drug is not valid."
                                 reqErrMsg="Non Group - HIC -> Total Number of Lives - Prescription Drug is required."></uc1:wucNumber>
                         </td>
                     </tr>
                     <tr>
                         <td class="FrmFieldTxt"><span class="Required">*</span> Total Number of Lives - 
																						    Vision:&nbsp;</td>
                         <td>
                             <uc1:wucNumber ID="wucHicNgrpVision" runat="server" Size="10" REQUIRED="true" invErrMsg="Non Group - HIC -> Total Number of Lives - Vision is not valid."
                                 reqErrMsg="Non Group - HIC -> Total Number of Lives - Vision is required."></uc1:wucNumber>
                         </td>
                     </tr>
                 </table>
            </div>
            <div class="FrmBackGrnd" style="border: 2px solid black; margin: 5px; ">
            <div class="FrmSecHead" style="background-color: #cccccc; height:15px;padding-top:5px;padding-bottom:5px; border-bottom: 2px solid black;">
                Group - Health Insuring Corporation (HMO Products)
            </div>
                <table cellspacing="2" cellpadding="2" width="100%" border="0" role="presentation">
                    <tr>
                        <td class="FrmFieldTxt"><span class="Required">*</span> Total Number of Lives - 
																						    Dental:&nbsp;</td>
                        <td>
                            <uc1:wucNumber ID="wucHicGrpDental" runat="server" Size="10" REQUIRED="true" invErrMsg="Group - HIC -> Total Number of Lives - Dental is not valid."
                                reqErrMsg="Group - HIC -> Total Number of Lives - Dental is required."></uc1:wucNumber>
                        </td>
                    </tr>
                    <tr>
                        <td class="FrmFieldTxt"><span class="Required">*</span> Total Number of Lives - 
																						    Prescription Drug:&nbsp;</td>
                        <td>
                            <uc1:wucNumber ID="wucHicGrpDrug" runat="server" Size="10" REQUIRED="true" invErrMsg="Group - HIC -> Total Number of Lives - Prescription Drug is not valid."
                                reqErrMsg="Group - HIC -> Total Number of Lives - Prescription Drug is required."></uc1:wucNumber>
                        </td>
                    </tr>
                    <tr>
                        <td class="FrmFieldTxt"><span class="Required">*</span> Total Number of Lives - 
																						    Vision:&nbsp;</td>
                        <td>
                            <uc1:wucNumber ID="wucHicGrpVision" runat="server" Size="10" REQUIRED="true" invErrMsg="Group - HIC -> Total Number of Lives - Vision is not valid."
                                reqErrMsg="Group - HIC -> Total Number of Lives - Vision is required."></uc1:wucNumber>
                        </td>
                    </tr>
                </table>
            </div>
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                <asp:button id="cmdSave" onclick="cmdSave_Click" Runat="server" text="Save"></asp:button>&nbsp;&nbsp;&nbsp;
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