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. . ~ . ~ CERTIFICATE OF MEMBERSHIP <br />. '~ <br />- ~REATER OREGON HEALTH SERVIC <br />GREATER OREGON HEALTH SERVICE, INC. <br />`.Post Office Box 1210 <br />~ Grants Pas~s, Oregon 97526 <br />, <br />HOSPITAL-SURGICAL-MEDICAL PLAN <br />PRINCIPAL MEMBER AGREEMENT EFFECTIVE <br />PETER V..HELZER Ddte MARCH 15 1988 ~ <br />Mo. Day Year <br />~ THIS AGREEMENT IS GUARANTEED RfNEWABLE FOR LIFE SUBJECT TO THE ASSOCIATION'S <br />RIGHT TO CHANGE SCHEDULE OF RATES APPLICABLE TO ALL MEMBERS ENROLLED IN THIS <br />PLAN AND TO CHANGE THE RENEWAL DUfS FOR THE AGREEMENT ACCORDINGLY. <br />NOTICE OF TEN DAY RIGHT TO EXAMINE: If within 10 days after its delivery, you <br />wish to return this agreement, you may do so. This will make it void from the <br />beginning as though it had not been written, and any dues you have paid under <br />this agreement will be refunded. <br />This is a legal contract. PLEASE READ IT CAREFULLY. <br />Please read the copy of.the application attached to this policy. This policy <br />. was issued based on the answers recorded on the application. If this appli~a- <br />tion contains any misstatements or omissions, G.O.H.S. may either rescind the <br />coverage or modify it retroactively to exclude benefits for the conditions not <br />reported correctly and any conditions related thereto. Review the application <br />and write us at the address shown above if any information is not correct or if <br />any past medical history has been left out. <br />INITIAL PREMIUM $. 17 7: 00 . <br />PAYS YOU TO JUNE 15 1988 <br />Mo. Day Year <br />MEMBERSHIP ENROLLMENT FEE $ 7.50 <br />Plan No. 8x55 When corresponding, please refer to Membership.No. 12 4607 <br />, <br />1 <br />