ࡱ> ?A<=>c bjbjZZ h8b\8b\  $,/r|jjjjEA"#-......$v0,3|%.%(EE%(%(%.jj.,,,%((jj-,%(-,,,jΩM(",-.0/,3o("3,3,$%,C&|&f$$$%.%.+$$$/%(%(%(%(3$$$$$$$$$ > H: NOTIFICATION OF INJURYThe Texas A&M University SystemWARNING: Any person who knowingly presents a false or fraudulent claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison.A.EXCESS COVERAGE Eligible covered expenses will be paid only if they are in excess of other valid and collectible insurance or medical payment plan, regardless of any Coordination of Benefits provision contained in such plan. If the claimant is covered by any other insurance or medical plan they must submit a claim to their primary insurance first. After the primary insurance has paid benefits, then submit this claim form along with all EOBs (explanation of benefits) from the primary insurance.B.Attach all medical bills. All bills submitted must be ITEMIZED for service. A balance due statement is not acceptable. A physicians office should submit an invoice per HCFA 1500. A hospital should submit an invoice per UB04. HCFA 1500 and UB04 are universal billing forms.C.The Claim must be submitted within 90 DAYS from the date of the accident.D.Forward additional bills as they are received. No additional claim form is needed. Keep copies of everything. CLAIM FILING: (Mail or Fax to) Relation Insurance Services - Claims Dept., P. O. Box 25936, Overland Park, KS 66225 Fax No.: (913) 327-7520. Electronic:  HYPERLINK "mailto:claims@relationinsurance.com" claims@relationinsurance.com For claim filing questions, please call (877) 246-6997.CLAIM STATUS: To check the status of a claim, please call (877) 246-6997. PART A This PART MUST be completed, dated and signed by an official of the Organization. 1. Name of Organization (Policyholder)The Texas A&M University System2. Policy No.US 9475543. Name of Organization or Team (if Different from Policyholder)Institution/Agency Name:  FORMTEXT      Camp Name: FORMTEXT      4. Address or Organization: (Street)(City) (State) (Zip) FORMTEXT      5. Name of Injured Person (Insured)? (First) (Middle) (Last) FORMTEXT      6. Date of Accident/Injury7. Injury Occurred:8. Type of Sport or Activity:Mo. Day YearPractice  FORMCHECKBOX  Travel  FORMCHECKBOX  Game  FORMCHECKBOX  FORMTEXT      Other: FORMTEXT      9.. Explain HOW the accident and injury occurred. NOTE: If your organization uses an Accident Report, attached a copy of the Report. FORMTEXT      10. Describe the nature of injury.11. At the time of the accident, was the Person involved in an activity under the jurisdiction of the Organization (Policyholder)? Yes  FORMCHECKBOX  No  FORMCHECKBOX 12. Name of Supervisor of Activity.  FORMTEXT       13. Was he/she a witness to the injury? Yes  FORMCHECKBOX  No  FORMCHECKBOX 14. Signature of Organization Official15. Title of Official16. Area Code/Telephone No.17. Date SignedX_______________________________ FORMTEXT       FORMTEXT       FORMTEXT       PART B This PART MUST be completed, dated and signed by the injured Person or if the injured Person is under the age of 18 or otherwise dependent by his/her Parent or Guardian. Print Here NAME OF PERSON COMPLETING FORMCircle One: Injured Person  FORMCHECKBOX  Parent  FORMCHECKBOX  Guardian  FORMCHECKBOX Give the following information about the injured person: 1. Date of Birth Mo. Day Year. 2. Male  FORMCHECKBOX  Female  FORMCHECKBOX 3. Social Security No. or Student Visa No.  FORMTEXT       4. Area Code/Telephone No.  FORMTEXT       5. Address: (Street) (City) (State) (Zip) FORMTEXT      6. Employer (Name) (Street) (City) (State) (Zip)  FORMTEXT       Area Code/Telephone No. FORMTEXT      7. Is the injured Person covered under any other health and/or accident insurance plan? 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lap(yt~]X"Z"n"p"r"|"~"""""""""ꕃr]L4]/jaIh~]h.CJOJQJU^JaJ h~]h.CJOJQJ^JaJ)jh~]h.CJOJQJU^JaJ h~]h4CJOJQJ^JaJ#h~]h 5CJOJQJ^JaJ h~]h CJOJQJ^JaJ4jh~]hN!CJOJQJU^JaJmHnHu/jEHh~]h.CJOJQJU^JaJ h~]hN!CJOJQJ^JaJ)jh~]hN!CJOJQJU^JaJ""""" $IfgdhvkdH$$IflF(*0'  tP+    44 lapyt~]"""""#######$ bp<BFпpnVEEEE h~]h%nCJOJQJ^JaJ/jKh~]h3&CJOJQJU^JaJU/jeKh~]h3&CJOJQJU^JaJ)jh~]h3&CJOJQJU^JaJ h~]h3&CJOJQJ^JaJ h~]hCJ OJQJ^JaJ h~]h4CJOJQJ^JaJ)jh~]h.CJOJQJU^JaJ4jh~]h.CJOJQJU^JaJmHnHu"""""" $IfgdhvkdI$$IflF(*0'  tP+    44 lapyt~]""" qhhh $Ifgdhkd}J$$Ifl\}(*^  tP+44 lap(yt~]OX  If YES, give the following information:Name of Policyholder(s)Address of Other Insurance CompanyPolicy Number(s)Name of Insurance Company(s) FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT      8. If the Injured Person us under 18 or otherwise dependent, give the following information:Name of Father or Male GuardianSocial Security No. FORMTEXT       FORMTEXT      Place of Employment FORMTEXT      Address of EmployerArea Code/Employer Phone No. FORMTEXT       FORMTEXT      Name of Mother or Female GuardianSocial Security No. FORMTEXT      Place of Employment FORMTEXT       FORMTEXT      Address of EmployerArea Code/Employer Phone No. FORMTEXT       FORMTEXT      9. If the Injured Person is married, give the following information:Name of SpouseSocial Security No. FORMTEXT      Place of Employment FORMTEXT       FORMTEXT      Address of EmployerArea Code/Employer Phone No. FORMTEXT       FORMTEXT      I hereby authorize any Health Care Provider, Insurance Company, Employer, Person or Organization to release information regarding medical, dental, mental, drug or alcohol history, treatment or benefits payable, including disability or employment related information, to Summit America Insurance Services, L.C., the Plan Administrator or their employees and authorized agents for the purpose of validating and determining benefits payable. Any information obtained will not be released by the Company except to persons or organizations performing business or legal services in connection with my application or claim. A photocopy of this authorization shall be valid as the original and is valid for 24 months from the date shown below. I understand that I or my authorized representative will receive a copy of this authorization upon request. FORMCHECKBOX Injured PersonX________________________________ FORMTEXT      Mark One FORMCHECKBOX ParentDate FORMTEXT      Signature (in writing) of Responsible PartyPrint Name FORMCHECKBOX Guardian df|o| $If^gd~] $IfgdhykdQL$$Ifl4F(*`0'`  tP+    44 lapyt~]fhjln||| $IfgdhykdM$$Ifl4F(* 0'   tP+    44 lapyt~]npr DF|o|||| $If^gd~] $IfgdhykdM$$Ifl4F(* 0'   tP+    44 lapyt~]FHJLN=444 $IfgdhkdvN$$Ifl4ֈ (* T  Q    tP+44 lap<yt~]FHPRThjlvxz|͸͠͸m͸U͸/j&Qh~]h.CJOJQJU^JaJ/jPh~]h.CJOJQJU^JaJ4jh~]h.CJOJQJU^JaJmHnHu/j:Ph~]h.CJOJQJU^JaJ)jh~]h.CJOJQJU^JaJ h~]h.CJOJQJ^JaJ h~]h3&CJOJQJ^JaJ h~]h+CJOJQJ^JaJNPRz|||||| $IfgdhykdO$$Ifl4F(* 0'   tP+    44 lapyt~] FH\^`jlnҷҦr`rҦHҷr/jIWh~]h.CJOJQJU^JaJ#h~]h%n5CJOJQJ^JaJ h~]h%nCJOJQJ^JaJ#h~]h5CJ OJQJ^JaJ h~]hCJ OJQJ^JaJ h~]h.CJOJQJ^JaJ4jh~]h.CJOJQJU^JaJmHnHu)jh~]h.CJOJQJU^JaJ/jQh~]h.CJOJQJU^JaJ=4444 $IfgdhkdR$$Ifl4hֈw (*       tP+44 lap<yt~]qhhhh $IfgdhkdS$$Ifl\}(*^  tP+44 lap(yt~] qhhh $IfgdhkdT$$Ifl\}(*^  tP+44 lap(yt~] $IfgdhvkdT$$IflF(*0'  tP+    44 lapyt~]@Bqh[hh $If^gd~] $IfgdhkdU$$Ifl\S(*  tP+44 lap(yt~]BDFnqh[hh $If^gd~] $IfgdhkdoV$$Ifl\S(*  tP+44 lap(yt~]np׽~m~~XG/X/jYh~]h.CJOJQJU^JaJ h~]h.CJOJQJ^JaJ)jh~]h.CJOJQJU^JaJ h~]h4CJOJQJ^JaJ h~]h%nCJOJQJ^JaJ#h~]h%n5CJOJQJ^JaJ7jh~]h.5CJOJQJU^JaJmHnHu2jWh~]h.5CJOJQJU^JaJ#h~]h.5CJOJQJ^JaJ,jh~]h.5CJOJQJU^JaJqh[hh $If^gd~] $Ifgdhkd5X$$Ifl\S(*  tP+44 lap(yt~]qh[hh $If^gd~] $IfgdhkdY$$Ifl\S(*  tP+44 lap(yt~]bdfz|~пzbЋK9#h~]h.5CJOJQJ^JaJ,jh~]h.5CJOJQJU^JaJ/j\h~]h.CJOJQJU^JaJ h~]h.CJOJQJ^JaJ h~]hCJOJQJ^JaJ h~]hhCJOJQJ^JaJ#h~]h%n5CJOJQJ^JaJ h~]h%nCJOJQJ^JaJ)jh~]h.CJOJQJU^JaJ4jh~]h.CJOJQJU^JaJmHnHu$^`qh[hh $If^gd~] $Ifgdhkd_Z$$Ifl\S(*  tP+44 lap(yt~]`bdqh[hh $If^gd~] $Ifgdhkd9[$$Ifl\S(*  tP+44 lap(yt~]BDϳϡm\K\K\6)jh~]h.CJOJQJU^JaJ h~]h4CJOJQJ^JaJ h~]hhCJOJQJ^JaJ#h~]h5CJ OJQJ^JaJ h~]hCJ OJQJ^JaJ h~]hCJOJQJ^JaJ#h~]h5CJOJQJ^JaJ7jh~]h.5CJOJQJU^JaJmHnHu,jh~]h.5CJOJQJU^JaJ2j\h~]h.5CJOJQJU^JaJqhhhh $Ifgdhkd\$$Ifl\S(*  tP+44 lap(yt~]qhhhhh $Ifgdhkd]$$Ifl\}(*^  tP+44 lap(yt~]<>YPCPP $If^gd~] $Ifgdhkd^$$Iflr (* , (  tP+44 lap2yt~]>@Bjlnqh[hh $If^gd~] $Ifgdhkd_$$Ifl\S(*  tP+44 lap(yt~]DXZ\fhjl§–s\J0\2jah~]h.5CJOJQJU^JaJ#h~]h.5CJOJQJ^JaJ,jh~]h.5CJOJQJU^JaJ h~]h4CJOJQJ^JaJ#h~]hh5CJOJQJ^JaJ h~]hhCJOJQJ^JaJ4jh~]h.CJOJQJU^JaJmHnHu)jh~]h.CJOJQJU^JaJ/j`h~]h.CJOJQJU^JaJ h~]h.CJOJQJ^JaJnprqh[hh $If^gd~] $Ifgdhkda$$Ifl\S(*  tP+44 lap(yt~]`bvxz̺kP8P/jWeh~]h.CJOJQJU^JaJ4jh~]h.CJOJQJU^JaJmHnHu/j-ch~]h.CJOJQJU^JaJ h~]h.CJOJQJ^JaJ)jh~]h.CJOJQJU^JaJ h~]hhCJOJQJ^JaJ#h~]hh5CJOJQJ^JaJ,jh~]h.5CJOJQJU^JaJ7jh~]h.5CJOJQJU^JaJmHnHuqh[hh $If^gd~] $IfgdhkdSb$$Ifl\S(*  tP+44 lap(yt~] Z\qh[hh $If^gd~] $Ifgdhkdc$$Ifl\S(*  tP+44 lap(yt~]\^`qh[hh $If^gd~] $Ifgdhkd}d$$Ifl\S(*  tP+44 lap(yt~]bdzӼ}l}[}[}}[}F5 h~]h.CJOJQJ^JaJ)jh~]h.CJOJQJU^JaJ h~]h4CJOJQJ^JaJ h~]hCJ OJQJ^JaJ h~]hhCJOJQJ^JaJ#h~]hh5CJOJQJ^JaJ7jh~]h.5CJOJQJU^JaJmHnHu,jh~]h.5CJOJQJU^JaJ2jeh~]h.5CJOJQJU^JaJ#h~]h.5CJOJQJ^JaJqhhh[h -$If^-gd~] $IfgdhkdCf$$Ifl\S(*  tP+44 lap(yt~]YPPPPP $Ifgdhkdg$$Iflr (* , (  tP+44 lap2yt~]Z\YPPP $Ifgdhkdh$$Iflr (* , (  tP+44 lap2yt~]\^`bdf $Ifgdhvkdi$$IflF(*0'  tP+    44 lapyt~]fhjqh[hh $If^gd~] $Ifgdhkdi$$Ifl\S(*  tP+44 lap(yt~]qh[hh $If^gd~] $Ifgdhkdj$$Ifl\S(*  tP+44 lap(yt~] $&(ҷҦlZ@l2jlh~]h.5CJOJQJU^JaJ#h~]h.5CJOJQJ^JaJ,jh~]h.5CJOJQJU^JaJ h~]h4CJOJQJ^JaJ#h~]hh5CJOJQJ^JaJ h~]hhCJOJQJ^JaJ4jh~]h.CJOJQJU^JaJmHnHu)jh~]h.CJOJQJU^JaJ/jikh~]h.CJOJQJU^JaJ 68qh[hh $If^gd~] $Ifgdhkdk$$Ifl\S(*  tP+44 lap(yt~](246<>RTV`bdf̺kP8P/j3ph~]h.CJOJQJU^JaJ4jh~]h.CJOJQJU^JaJmHnHu/j nh~]h.CJOJQJU^JaJ h~]h.CJOJQJ^JaJ)jh~]h.CJOJQJU^JaJ h~]hhCJOJQJ^JaJ#h~]hh5CJOJQJ^JaJ,jh~]h.5CJOJQJU^JaJ7jh~]h.5CJOJQJU^JaJmHnHu8:<dfhqh[hh $If^gd~] $Ifgdhkd/m$$Ifl\S(*  tP+44 lap(yt~]hjlqh[hh $If^gd~] $Ifgdhkdn$$Ifl\S(*  tP+44 lap(yt~]$&qh[hh $If^gd~] $IfgdhkdYo$$Ifl\S(*  tP+44 lap(yt~] "$(0>J|RV`ddjӼ}l[}J9J9J9J9J9J9 h~]hZ CJOJQJ^JaJ h~]h+CJOJQJ^JaJ h~]hCJ OJQJ^JaJ h~]hCJOJQJ^JaJ h~]hhCJOJQJ^JaJ#h~]hh5CJOJQJ^JaJ7jh~]h.5CJOJQJU^JaJmHnHu,jh~]h.5CJOJQJU^JaJ2jph~]h.5CJOJQJU^JaJ#h~]h.5CJOJQJ^JaJ&(*,.qhhh $Ifgdhkdq$$Ifl\S(*  tP+44 lap(yt~].02468:< $Ifgdhvkdq$$IflF(*0'  tP+    44 lapyt~]<>@BDA88+ %$If^%gd~] $Ifgdhkdr$$Iflֈ *"(* X K   tP+44 lap<yt~]DFHJLNC6 %$If^%gd~]kds$$Iflr'(*5%  tP+44 lap2yt~] $Ifgdh 8$If^8gd~]8l(ͼ﫼m\K9#h~]h+5CJOJQJ^JaJ h~]h4CJOJQJ^JaJ h~]h+CJOJQJ^JaJ/jLh~]hCJ OJQJU^JaJ h~]h+CJ OJQJ^JaJ )jh~]h+CJ OJQJU^JaJ h~]h4CJ OJQJ^JaJ h~]h4CJOJQJ^JaJ h~]h+WgCJOJQJ^JaJ h~]hZ CJOJQJ^JaJ h~]h+CJOJQJ^JaJAkdt$$Ifl4r'(*`5%  tP+44 lap2yt~] $Ifgdh 8$If^8gd~]4kdyu$$Ifl4r'(* 5%  tP+44 lap2yt~] $Ifgdh 8$If^8gd~] %$If^%gd~]4kdWv$$Ifl4r'(* 5%  tP+44 lap2yt~] 8$If^8gd~] %$If^%gd~] $Ifgdh   8$If^8gd~] %$If^%gd~] $IfgdhWNNA4 8$If^8gd~] %$If^%gd~] $Ifgdhkd5w$$Ifl4r'(* 5%  tP+44 lap2yt~] "$&NA %$If^%gd~]kdx$$Ifl4r'(* 5%  tP+44 lap2yt~] $Ifgdh&(*,.0Akdx$$Ifl4r'(* 5%  tP+44 lap2yt~] $Ifgdh 8$If^8gd~]024684kdy$$Ifl4r'(* 5%  tP+44 lap2yt~] $Ifgdh 8$If^8gd~] %$If^%gd~]8:<>@BDFHJLNPRTVXZ\^`bdfFfG| 8$If^8gd~] %$If^%gd~] $$Ifa$gd~] $Ifgd+Wgfhjlnprtvxz|~Ff %$If^%gd~] $$Ifa$gd~] $IfgdFf| $Ifgd+Wg 8$If^8gd~]&(Pb%$If]^%gd~] $Ifgd. $$Ifa$gd~]Ff\ $Ifgd 8$If^8gd~] %$If^%gd~](*>@BLNPXbdꕄs^M5^Ms/jmh~]h+CJ OJQJU^JaJ h~]h+CJ OJQJ^JaJ )jh~]h+CJ OJQJU^JaJ h~]h+CJOJQJ^JaJ h~]hCJOJQJ^JaJ h~]h+CJOJQJ^JaJ4jh~]h.CJOJQJU^JaJmHnHu/jh~]h.CJOJQJU^JaJ h~]h.CJOJQJ^JaJ)jh~]h.CJOJQJU^JaJBD`bdfvꕄo^Fo^^5 h~]hhCJOJQJ^JaJ/jh~]hCJOJQJU^JaJ h~]h+CJOJQJ^JaJ)jh~]h+CJOJQJU^JaJ h~]h4CJOJQJ^JaJ h~]h+CJ OJQJ^JaJ 4jh~]h|DCJ OJQJU^JaJ mHnHu/jh~]h|DCJ OJQJU^JaJ h~]h|DCJ OJQJ^JaJ )jh~]h|DCJ OJQJU^JaJ *@Bfxz|~Ff 8$If^8gd~] %$If^%gd~] $$Ifa$gd~] $IfgdhFf5A88888 $Ifgdhkd$$Iflֈ'(*&  tP+44 lap<yt~]61gd+Wgkd$$Ifluֈ *"(* X K   tP+44 lap<yt~] $Ifgdh hUhL h~]hCJOJQJ^JaJ21h:pS/ =!"#$% 21h:pS/ =!"#$% $$If!vh#v@#vg#v]:V l tP+6L5@5g5]pyt~]$$If!vh#v@#vT#vp:V l tP+6L5@5T5ppyt~]R$$If!vh#v+:V l tP+6L5+p yt~]$$If!vh#v@#v2 #v:V l tP+6L5@52 5pyt~]j$$If!vh#v#v3):V l tP+6L553)pyt~]j$$If!vh#v#v3):V l tP+6L553)pyt~]R$$If!vh#v+:V l tP+6L5+p yt~]j$$If!vh#v#v3):V l tP+6L553)pyt~]j$$If!vh#v#v3):V l tP+6L553)pyt~]j$$If!vh#v#v(:V l tP+6L55(pyt~]R$$If!vh#v+:V l tP+6L5+p yt~]R$$If!vh#v+:V l tP+6L5+p yt~]n$$If!vh#v#v(:V lP tP+6L55(pyt~]$$If!vh#v+#vP#v#v:V l tP+65+5P55/ / / /  / / p(yt~]$$If!vh#v+#v '#v:V l tP+65+5 '5/  / / pyt~]$$If!vh#v+#vP#v#v:V l tP+65+5P55/ / / /  / / p(yt~]$$If!vh#v+#v #v#v:V l tP+65+5 55/ / / / / p(yt~]$$If!vh#v+#vP#v#v:V l tP+65+5P55/ / / / /  / p(yt~]$$If!vh#v+#vP#v#v:V l tP+65+5P55/ / / /  / / p(yt~]$$If!vh#v+#vE#v!#v:V l tP+65+5E5!5/ / / / / p(yt~]$$If!vh#v+#vP#v#v:V l tP+65+5P55/ / / / /  / p(yt~]$$If!vh#v+#vP#v#v:V l tP+65+5P55/ / / /  / / p(yt~]vDText40$$If!vh#v+#vP#vy#v@ #v:V l tP+65+5P5y5@ 5/ / / / / p2yt~]vDText39$$If!vh#v+#v#v\ #v:V l tP+65+55\ 5/ / / / / / p(yt~]$$If!vh#v+#vP#v#v:V l tP+65+5P55/ / / /  / / p(yt~]$$If!vh#v+#vP#v#v:V l tP+65+5P55/ / / / / p(yt~]tDText4$$If!vh#v+#v '#v:V l tP+65+5 '5/  / / pyt~]$$If!vh#v+#vP#v#v:V l tP+65+5P55/ / / / /  / p(yt~]$$If!vh#v+#vP#v#v:V l tP+65+5P55/ / / / / / p(yt~]$$If!vh#v+#vP#v#v:V l tP+65+5P55/ / / / / p(yt~]tDText3$$If!vh#v+#v #v$#v:V l tP+65+5 5$5/ / / / / p(yt~]$$If!vh#v+#vP#v#v:V l tP+65+5P55/ / / / /  / p(yt~]$$If!vh#v+#v #v #vE #v:V l tP+65+5 5 5E 5/  / / p2yt~]$$If!vh#v+#v #v #vE #v:V l tP+65+5 5 5E 5/  / / p2yt~]tDeCheck1tDeCheck2tDeCheck3$$If!vh#v+#v #v #vE #v:V l tP+65+5 5 5E 5/  / / p2yt~]tDText1tDText2'$$If!vh#v+#v #v4#v{ #vE #v:V l tP+65+5 545{ 5E 5/  / / / /  / / p<yt~]$$If!vh#v+#v #v #vE #v:V l tP+65+5 5 5E 5/ / / p2yt~]$$If!vh#v+#v #v #vE #v:V l tP+65+5 5 5E 5/ / / / / / p2yt~]$$If!vh#v+#v '#v:V l tP+65+5 '5/  / / pyt~]tDText6$$If!vh#v+#v '#v:V l4 tP+6+5+5 '5/  / / pyt~]$$If!vh#v+#v '#v:V l4 tP+6+5+5 '5/  / / pyt~]$$If!vh#v+#v '#v:V l4 tP+6+5+5 '5/  / / pyt~]$$If!vh#v+#v '#v:V l4 tP+6+5+5 '5/  / / pyt~]$$If!vh#v+#v '#v:V l4 tP+6+5+5 '5/  / / pyt~]$$If!vh#v+#v '#v:V l4 tP+6+5+5 '5/ / / pyt~]$$If!vh#v+#v '#v:V l tP+65+5 '5/  / / pyt~]$$If!vh#v+#v '#v:V l tP+65+5 '5/  / / pyt~]$$If!vh#v+#v '#v:V l4 tP+6+5+5 '5/  / / pyt~]$$If!vh#v+#v '#v:V l4 tP+6+5+5 '5/  / / pyt~]$$If!vh#v+#v '#v:V l4 tP+6+5+5 '5/  / / pyt~]$$If!vh#v+#v '#v:V l4 tP+6+5+5 '5/  / / pyt~]$$If!vh#v+#v '#v:V l4 tP+6+5+5 '5/  / / pyt~]$$If!vh#v+#v '#v:V l4 tP+6+5+5 '5/  / / pyt~]$$If!vh#v+#v '#v:V l4P tP+6+5+5 '5/ / / pyt~]$$If!vh#v+#v #v,#v #v:V l tP+65+5 5,5 5/  / / p2yt~]tDeCheck4tDeCheck5tDText8tDeCheck6tDeCheck7$$If!vh#v+#v #v,#v #v:V l4 tP+6+5+5 5,5 5/  / / p2yt~]$$If!vh#v+#v #v,#v #v:V l4 tP+6+5+5 5,5 5/ / / p2yt~]$$If!vh#v+#v #v #v #vX#v:V l tP+65+5 5 5 5X5/  / / / p<yt~]$$If!vh#v+#v #v #v #vX#v:V l tP+65+5 5 5 5X5/  / / p<yt~]$$If!vh#v+#v #v #v #vX#v:V l tP+65+5 5 5 5X5/  / / p<yt~]tDText9vDText10vDText11$$If!vh#v+#v #v #v #vX#v:V l tP+65+5 5 5 5X5/  / / p<yt~]$$If!vh#v+#v #v #v #vX#v:V l tP+65+5 5 5 5X5/ / / p<yt~]$$If!vh#v#v#v^#v :V l tP+555^5 / / / /  / / p(yt~]$$If!vh#v#v0'#v :V l tP+550'5 /  / / pyt~]$$If!vh#v#v#v^#v :V l tP+555^5 / / / /  / / p(yt~]tDeCheck8tDeCheck9vDeCheck10$$If!vh#v#v/#v#v :V l tP+55/55 / / / / p(yt~]$$If!vh#v#v#v^#v :V l tP+555^5 / / / / / p(yt~]$$If!vh#v#v#v^#v :V l tP+555^5 / / / / /  / p(yt~]$$If!vh#v#v#v^#v :V l tP+555^5 / / / /  / / p(yt~]$$If!vh#v#v0'#v :V l tP+550'5 /  / / pyt~]$$$If!vh#v#v@#v5#v#v #v :V l tP+55@5555 5 / /  / / /  / / p<yt~]vDeCheck12vDeCheck11vDText12vDText13$$If!vh#v#v@#v5#v#v #v :V l tP+55@5555 5 / /  / / / / p<yt~]$$$If!vh#v#v@#v5#v#v #v :V l tP+55@5555 5 / / / / / /  / p<yt~]$$If!vh#v#v#v^#v :V l tP+555^5 / / / /  / / p(yt~]$$If!vh#v#v2#v!#v :V l tP+5525!5 / / / / / p(yt~]vDText34$$If!vh#v#v2#v!#v :V l tP+5525!5 / / / / / p(yt~]$$If!vh#v#v#v^#v :V l tP+555^5 / / / / /  / p(yt~]$$If!vh#v#v#v^#v :V l tP+555^5 / / / /  / / p(yt~]vDText14$$If!vh#v#v0'#v :V l tP+550'5 /  / / pyt~]vDText16$$If!vh#v#v0'#v :V l tP+550'5 / / / pyt~]$$If!vh#v#v#v^#v :V l tP+555^5 / / / /  / / p(yt~]vDeCheck13vDeCheck14$$If!vh#v#v0'#v :V l4 tP+++550'5 /  / / pyt~]$$If!vh#v#v0'#v :V l4 tP+++550'5 /  / / pyt~]$$If!vh#v#v0'#v :V l4 tP+++550'5 /  / / pyt~] $$If!vh#v#vT #v #vQ#v #v :V l4 tP+++55T 5 5Q5 5 / / / / p<yt~]$$If!vh#v#v0'#v :V l4 tP+++550'5 /  / / 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