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2012-01-24T15:16:43-06:00 Adobe InDesign 7.5 /;/metadata saved xmp.iid:BB6EEC35D02568118083FF3CE9E2FB47 2012-01-26T11:43:40-06:00 Adobe InDesign 7.5 /;/metadata xmp.iid:59EAF459982468118083FF3CE9E2FB47 xmp.did:57EAF459982468118083FF3CE9E2FB47 xmp.did:1AE101044D216811871FFFA44E3A235E default 14487 application/pdf World Bank 3339812 ADA Claim Form IT OPS - ODS/AFDDS KGabriel J430D_Dental Claim Form_2012 CAT. NO. 590154f ADA Claim Dental American Association Adobe LiveCycle Designer 11.0 False ADA, Claim, Dental, American, Association PDF/X-1:2001 PDF/X-1:2001 PDF/X-1a:2001 1 1.1 endstream endobj 51 0 obj <>>>/Metadata 24 0 R/Names 321 0 R/Outlines 36 0 R/PageLabels 46 0 R/Pages 48 0 R/Perms<<>>/Type/Catalog>> endobj 55 0 obj <> endobj 1544 0 obj [1546 0 R 1547 0 R 1548 0 R 1549 0 R 1550 0 R 1551 0 R 1552 0 R 1553 0 R 1554 0 R 1555 0 R 1556 0 R 1557 0 R 1558 0 R 1559 0 R 1560 0 R 1561 0 R 1562 0 R 1563 0 R 1564 0 R 1565 0 R 1566 0 R 1567 0 R 1568 0 R 1569 0 R 1570 0 R 1571 0 R 1572 0 R 1573 0 R 1574 0 R 1575 0 R 1576 0 R 1577 0 R 1578 0 R 1579 0 R 1580 0 R 1581 0 R 1582 0 R 1583 0 R 1584 0 R 1585 0 R 1586 0 R 1587 0 R 1588 0 R 1589 0 R 1590 0 R 1591 0 R 1592 0 R 1593 0 R 1594 0 R 1595 0 R 1596 0 R 1597 0 R 1598 0 R 1599 0 R 1600 0 R 1601 0 R 1602 0 R 1603 0 R 1604 0 R 1605 0 R 1606 0 R 1607 0 R 1608 0 R 1609 0 R 1610 0 R 1611 0 R 1612 0 R 1613 0 R 1614 0 R 1615 0 R 1616 0 R 1617 0 R 1618 0 R 1619 0 R 1620 0 R 1621 0 R 1622 0 R 1623 0 R 1624 0 R 1625 0 R 1626 0 R 1627 0 R 1628 0 R 1629 0 R 1630 0 R 1631 0 R 1632 0 R 1633 0 R 1634 0 R 1635 0 R 1636 0 R 1637 0 R 1638 0 R 1639 0 R 1640 0 R 1641 0 R 1642 0 R 1643 0 R 1644 0 R 1645 0 R 1646 0 R 1647 0 R 1648 0 R 1649 0 R 1650 0 R 1651 0 R 1652 0 R 1653 0 R 1654 0 R 1655 0 R 1656 0 R 1657 0 R 1658 0 R 1659 0 R 1660 0 R 1661 0 R 1662 0 R 1663 0 R 1664 0 R 1665 0 R 1666 0 R 1667 0 R 1668 0 R 1669 0 R 1670 0 R 1671 0 R 1672 0 R 1673 0 R 1674 0 R 1675 0 R 1676 0 R 1677 0 R 1678 0 R 1679 0 R 1680 0 R 1681 0 R 1682 0 R 1683 0 R 1684 0 R 1685 0 R 1686 0 R 1687 0 R 1688 0 R 1689 0 R 1690 0 R 1691 0 R 1692 0 R 1693 0 R 1694 0 R 1695 0 R 1696 0 R 1697 0 R 1698 0 R 1699 0 R 1700 0 R 1701 0 R 1702 0 R 1703 0 R 1704 0 R 1705 0 R 1706 0 R 1707 0 R 1708 0 R 1709 0 R 1710 0 R 1711 0 R 1712 0 R 1713 0 R 1714 0 R 1715 0 R 1716 0 R 1717 0 R 1718 0 R 1719 0 R 1720 0 R 1721 0 R 1722 0 R 1723 0 R 1724 0 R 1725 0 R 1726 0 R 1727 0 R 1728 0 R 1729 0 R 1730 0 R 1731 0 R 1732 0 R 1733 0 R 1734 0 R 1735 0 R 1736 0 R 1737 0 R 1738 0 R 1739 0 R 1740 0 R 1741 0 R 1742 0 R 1743 0 R 1744 0 R 1745 0 R 1746 0 R 1747 0 R 1748 0 R 1749 0 R 1750 0 R 1751 0 R 1752 0 R 1753 0 R 1754 0 R 1755 0 R 1756 0 R 1757 0 R 1758 0 R 1759 0 R 1760 0 R 1761 0 R 1762 0 R] endobj 1545 0 obj [300 0 R 301 0 R 302 0 R 303 0 R 304 0 R 305 0 R 306 0 R 307 0 R] endobj 1546 0 obj <>/BS<>/DA(/MyriadPro-Regular 8 Tf 0 0 1 rg)/F 4/FT/Btn/Ff 65536/H/N/MK<>/P 55 0 R/Parent 1763 0 R/Rect[459.269 720.782 572.598 730.372]/Subtype/Widget/T(EmailSubmitButton1[0])/TU(WBGUSDentalClaims@cigna.com)/Type/Annot>> endobj 1547 0 obj <>/P 55 0 R/Parent 1763 0 R/Rect[316.959 721.001 461.5 735.531]/Subtype/Widget/T(brand1[0])/TU(brand1)/Type/Annot>> endobj 1548 0 obj <>/N<>>>/AS/Off/BS<>/F 4/FT/Btn/MK<>/P 55 0 R/Parent 1763 0 R/Rect[23.876 731.959 34.058 742.141]/Subtype/Widget/T(Check_Box5[0])/TU(Check_Box5)/Type/Annot>> endobj 1549 0 obj <>/P 55 0 R/Parent 1763 0 R/Rect[15.96 694.8 305.76 710.64]/Subtype/Widget/T(_2_PredeterminationPreauthorization_Number[0])/TU(2. 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NO. 590154f ADA Claim Dental American Association Adobe LiveCycle Designer 11.0 False ADA, Claim, Dental, American, Association PDF/X-1:2001 PDF/X-1:2001 PDF/X-1a:2001 1 1.1 endstream endobj 51 0 obj <>>>/Metadata 24 0 R/Names 321 0 R/Outlines 36 0 R/PageLabels 46 0 R/Pages 48 0 R/Perms<<>>/Type/Catalog>> endobj 55 0 obj <> endobj 2029 0 obj [2031 0 R 2032 0 R 2033 0 R 2034 0 R 2035 0 R 2036 0 R 2037 0 R 2038 0 R 2039 0 R 2040 0 R 2041 0 R 2042 0 R 2043 0 R 2044 0 R 2045 0 R 2046 0 R 2047 0 R 2048 0 R 2049 0 R 2050 0 R 2051 0 R 2052 0 R 2053 0 R 2054 0 R 2055 0 R 2056 0 R 2057 0 R 2058 0 R 2059 0 R 2060 0 R 2061 0 R 2062 0 R 2063 0 R 2064 0 R 2065 0 R 2066 0 R 2067 0 R 2068 0 R 2069 0 R 2070 0 R 2071 0 R 2072 0 R 2073 0 R 2074 0 R 2075 0 R 2076 0 R 2077 0 R 2078 0 R 2079 0 R 2080 0 R 2081 0 R 2082 0 R 2083 0 R 2084 0 R 2085 0 R 2086 0 R 2087 0 R 2088 0 R 2089 0 R 2090 0 R 2091 0 R 2092 0 R 2093 0 R 2094 0 R 2095 0 R 2096 0 R 2097 0 R 2098 0 R 2099 0 R 2100 0 R 2101 0 R 2102 0 R 2103 0 R 2104 0 R 2105 0 R 2106 0 R 2107 0 R 2108 0 R 2109 0 R 2110 0 R 2111 0 R 2112 0 R 2113 0 R 2114 0 R 2115 0 R 2116 0 R 2117 0 R 2118 0 R 2119 0 R 2120 0 R 2121 0 R 2122 0 R 2123 0 R 2124 0 R 2125 0 R 2126 0 R 2127 0 R 2128 0 R 2129 0 R 2130 0 R 2131 0 R 2132 0 R 2133 0 R 2134 0 R 2135 0 R 2136 0 R 2137 0 R 2138 0 R 2139 0 R 2140 0 R 2141 0 R 2142 0 R 2143 0 R 2144 0 R 2145 0 R 2146 0 R 2147 0 R 2148 0 R 2149 0 R 2150 0 R 2151 0 R 2152 0 R 2153 0 R 2154 0 R 2155 0 R 2156 0 R 2157 0 R 2158 0 R 2159 0 R 2160 0 R 2161 0 R 2162 0 R 2163 0 R 2164 0 R 2165 0 R 2166 0 R 2167 0 R 2168 0 R 2169 0 R 2170 0 R 2171 0 R 2172 0 R 2173 0 R 2174 0 R 2175 0 R 2176 0 R 2177 0 R 2178 0 R 2179 0 R 2180 0 R 2181 0 R 2182 0 R 2183 0 R 2184 0 R 2185 0 R 2186 0 R 2187 0 R 2188 0 R 2189 0 R 2190 0 R 2191 0 R 2192 0 R 2193 0 R 2194 0 R 2195 0 R 2196 0 R 2197 0 R 2198 0 R 2199 0 R 2200 0 R 2201 0 R 2202 0 R 2203 0 R 2204 0 R 2205 0 R 2206 0 R 2207 0 R 2208 0 R 2209 0 R 2210 0 R 2211 0 R 2212 0 R 2213 0 R 2214 0 R 2215 0 R 2216 0 R 2217 0 R 2218 0 R 2219 0 R 2220 0 R 2221 0 R 2222 0 R 2223 0 R 2224 0 R 2225 0 R 2226 0 R 2227 0 R 2228 0 R 2229 0 R 2230 0 R 2231 0 R 2232 0 R 2233 0 R 2234 0 R 2235 0 R 2236 0 R 2237 0 R 2238 0 R 2239 0 R 2240 0 R 2241 0 R 2242 0 R 2243 0 R 2244 0 R 2245 0 R 2246 0 R 2247 0 R] endobj 2030 0 obj [300 0 R 301 0 R 302 0 R 303 0 R 304 0 R 305 0 R 306 0 R 307 0 R] endobj 2031 0 obj <>/BS<>/DA(/MyriadPro-Regular 8 Tf 0 0 1 rg)/F 4/FT/Btn/Ff 65536/H/N/MK<>/P 55 0 R/Parent 2248 0 R/Rect[459.269 720.782 572.598 730.372]/Subtype/Widget/T(EmailSubmitButton1[0])/TU(WBGUSDentalClaims@cigna.com)/Type/Annot>> endobj 2032 0 obj <>/P 55 0 R/Parent 2248 0 R/Rect[316.959 721.738 461.5 734.23]/Subtype/Widget/T(brand1[0])/TU(brand1)/Type/Annot>> endobj 2033 0 obj <>/N<>>>/AS/Off/BS<>/F 4/FT/Btn/MK<>/P 55 0 R/Parent 2248 0 R/Rect[23.876 731.959 34.058 742.141]/Subtype/Widget/T(Check_Box5[0])/TU(Check_Box5)/Type/Annot>> endobj 2034 0 obj <>/P 55 0 R/Parent 2248 0 R/Rect[15.96 694.8 305.76 710.64]/Subtype/Widget/T(_2_PredeterminationPreauthorization_Number[0])/TU(2. 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2012-01-24T14:26:14-06:00 Adobe InDesign 7.5 /;/metadata saved xmp.iid:539398329F2468118083FF3CE9E2FB47 2012-01-24T15:12:19-06:00 Adobe InDesign 7.5 /;/metadata saved xmp.iid:F2EFFDA69F2468118083FF3CE9E2FB47 2012-01-24T15:16:43-06:00 Adobe InDesign 7.5 /;/metadata saved xmp.iid:BB6EEC35D02568118083FF3CE9E2FB47 2012-01-26T11:43:40-06:00 Adobe InDesign 7.5 /;/metadata xmp.iid:59EAF459982468118083FF3CE9E2FB47 xmp.did:57EAF459982468118083FF3CE9E2FB47 xmp.did:1AE101044D216811871FFFA44E3A235E default 14487 application/pdf World Bank 3339812 ADA Claim Form IT OPS - ODS/AFDDS KGabriel J430D_Dental Claim Form_2012 CAT. NO. 590154f ADA Claim Dental American Association Adobe LiveCycle Designer 11.0 False ADA, Claim, Dental, American, Association PDF/X-1:2001 PDF/X-1:2001 PDF/X-1a:2001 1 1.1 endstream endobj 51 0 obj <>>>/Metadata 24 0 R/Names 321 0 R/Outlines 36 0 R/PageLabels 46 0 R/Pages 48 0 R/Perms<<>>/Type/Catalog>> endobj 55 0 obj <> endobj 2521 0 obj [2523 0 R 2524 0 R 2525 0 R 2526 0 R 2527 0 R 2528 0 R 2529 0 R 2530 0 R 2531 0 R 2532 0 R 2533 0 R 2534 0 R 2535 0 R 2536 0 R 2537 0 R 2538 0 R 2539 0 R 2540 0 R 2541 0 R 2542 0 R 2543 0 R 2544 0 R 2545 0 R 2546 0 R 2547 0 R 2548 0 R 2549 0 R 2550 0 R 2551 0 R 2552 0 R 2553 0 R 2554 0 R 2555 0 R 2556 0 R 2557 0 R 2558 0 R 2559 0 R 2560 0 R 2561 0 R 2562 0 R 2563 0 R 2564 0 R 2565 0 R 2566 0 R 2567 0 R 2568 0 R 2569 0 R 2570 0 R 2571 0 R 2572 0 R 2573 0 R 2574 0 R 2575 0 R 2576 0 R 2577 0 R 2578 0 R 2579 0 R 2580 0 R 2581 0 R 2582 0 R 2583 0 R 2584 0 R 2585 0 R 2586 0 R 2587 0 R 2588 0 R 2589 0 R 2590 0 R 2591 0 R 2592 0 R 2593 0 R 2594 0 R 2595 0 R 2596 0 R 2597 0 R 2598 0 R 2599 0 R 2600 0 R 2601 0 R 2602 0 R 2603 0 R 2604 0 R 2605 0 R 2606 0 R 2607 0 R 2608 0 R 2609 0 R 2610 0 R 2611 0 R 2612 0 R 2613 0 R 2614 0 R 2615 0 R 2616 0 R 2617 0 R 2618 0 R 2619 0 R 2620 0 R 2621 0 R 2622 0 R 2623 0 R 2624 0 R 2625 0 R 2626 0 R 2627 0 R 2628 0 R 2629 0 R 2630 0 R 2631 0 R 2632 0 R 2633 0 R 2634 0 R 2635 0 R 2636 0 R 2637 0 R 2638 0 R 2639 0 R 2640 0 R 2641 0 R 2642 0 R 2643 0 R 2644 0 R 2645 0 R 2646 0 R 2647 0 R 2648 0 R 2649 0 R 2650 0 R 2651 0 R 2652 0 R 2653 0 R 2654 0 R 2655 0 R 2656 0 R 2657 0 R 2658 0 R 2659 0 R 2660 0 R 2661 0 R 2662 0 R 2663 0 R 2664 0 R 2665 0 R 2666 0 R 2667 0 R 2668 0 R 2669 0 R 2670 0 R 2671 0 R 2672 0 R 2673 0 R 2674 0 R 2675 0 R 2676 0 R 2677 0 R 2678 0 R 2679 0 R 2680 0 R 2681 0 R 2682 0 R 2683 0 R 2684 0 R 2685 0 R 2686 0 R 2687 0 R 2688 0 R 2689 0 R 2690 0 R 2691 0 R 2692 0 R 2693 0 R 2694 0 R 2695 0 R 2696 0 R 2697 0 R 2698 0 R 2699 0 R 2700 0 R 2701 0 R 2702 0 R 2703 0 R 2704 0 R 2705 0 R 2706 0 R 2707 0 R 2708 0 R 2709 0 R 2710 0 R 2711 0 R 2712 0 R 2713 0 R 2714 0 R 2715 0 R 2716 0 R 2717 0 R 2718 0 R 2719 0 R 2720 0 R 2721 0 R 2722 0 R 2723 0 R 2724 0 R 2725 0 R 2726 0 R 2727 0 R 2728 0 R 2729 0 R 2730 0 R 2731 0 R 2732 0 R 2733 0 R 2734 0 R 2735 0 R 2736 0 R 2737 0 R 2738 0 R 2739 0 R] endobj 2522 0 obj [300 0 R 301 0 R 302 0 R 303 0 R 304 0 R 305 0 R 306 0 R 307 0 R] endobj 2523 0 obj <>/BS<>/DA(/MyriadPro-Regular 8 Tf 0 0 1 rg)/F 4/FT/Btn/Ff 65536/H/N/MK<>/P 55 0 R/Parent 2740 0 R/Rect[459.269 720.782 572.598 730.372]/Subtype/Widget/T(EmailSubmitButton1[0])/TU(WBGUSDentalClaims@cigna.com)/Type/Annot>> endobj 2524 0 obj <>/P 55 0 R/Parent 2740 0 R/Rect[316.959 721.939 461.5 734.967]/Subtype/Widget/T(brand1[0])/TU(brand1)/Type/Annot>> endobj 2525 0 obj <>/N<>>>/AS/Off/BS<>/F 4/FT/Btn/MK<>/P 55 0 R/Parent 2740 0 R/Rect[23.876 731.959 34.058 742.141]/Subtype/Widget/T(Check_Box5[0])/TU(Check_Box5)/Type/Annot>> endobj 2526 0 obj <>/P 55 0 R/Parent 2740 0 R/Rect[15.96 694.8 305.76 710.64]/Subtype/Widget/T(_2_PredeterminationPreauthorization_Number[0])/TU(2. 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xmp.did:1AE101044D216811871FFFA44E3A235E default 14487 application/pdf World Bank 3339812 ADA Claim Form IT OPS - ODS/AFDDS KGabriel J430D_Dental Claim Form_2012 CAT. 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