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Topeka KS 66629-0001 Phone 800 530-5989 Fax 785 290-0727 AICK 170 06/17 An independent licensee of the Blue Cross Blue Shield Association.. Otherwise they will need to request continuation of coverage under the Conversion Privilege. If you wish to be autodrafted for premiums please complete form AICK 25A Automatic Payment Authorization which is available on our website www. Advanceinsurance. com Section 3 Beneficiary Information If the designation of beneficiary shown below is different...
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