69O-149.054. Forms Incorporated by Reference

(1) The following forms are hereby adopted and incorporated by reference: (a) Form OIR-B2-570 (12/03) “General Information on Self-Funded Health Benefit Plans”; (b) Form OIR-B2-571 (12/03) “New Plan Operating Projections for Self-Funded Health Benefit Plans”; (c) Form OIR-B2-572 (12/03) “Annual Report of Self-Funded Health Benefit Plans”; (d) Form OIR-B2-573 (12/03) “Operating Projections for Self-Funded Health Benefit Plans”; (e) Form OIR-B2-574 (12/03) “General Information and Surplus Statement for Self-Funded Health Benefit Plans”; (2) The above forms are hereby adopted and incorporated by reference. (3) All forms are available and may be printed from the Office website: “http://www.floir.com/iportal.”