<?xml version="1.0" encoding="utf-8"?>
<dynaform.net xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance" xsi:noNamespaceSchemaLocation="M:\Inetpub\wwwroot\DynaForm.Net\DynaFormDotNet_V2.xsd">
	<settings>
		<printbreak>0</printbreak>
		<locationsortby>0</locationsortby>
		<sprayformdata>true</sprayformdata>
		<showelementsonly>false</showelementsonly>
		<printgroupids>false</printgroupids>
		<printvstickers>true</printvstickers>
		<createaddresslabel>false</createaddresslabel>
		<printlayoutgrid>false</printlayoutgrid>
		<allowprinting>true</allowprinting>
		<lockdownpdf>false</lockdownpdf>
		<outputdestination>client</outputdestination>
		<generator>pndc_client_consumer</generator>
	</settings>
	<firm>
		<name>Bluetooth Insurance Group</name>
		<address1>245 Spruce Avenue</address1>
		<address2>Suite 2000</address2>
		<city>Chicago</city>
		<state>IL</state>
		<postalcode>60611</postalcode>
		<phone>312-274-8791</phone>
		<fax>312-274-8793</fax>
		<url>http://www.blueinsgroup.com</url>
		<defnaic>247</defnaic>
		<deftextcolor>#0000FF</deftextcolor>
		<logoimg>big.jpg</logoimg>
		<signatureimg>bigsig.gif</signatureimg>
		<insureds>
			<insured>
				<orgname1>Filet Mignon Distribution</orgname1>
				<orgname2>A Division of Blank Angus, Inc.</orgname2>
				<fein>123456789</fein>
				<address1>1400 Bolvine Blvd</address1>
				<address2>Building 1C079</address2>
				<city>Dallas</city>
				<state>TX</state>
				<postalcode>75240</postalcode>
				<country>United States of America</country>
				<phone>817-244-7997</phone>
				<fax>817-244-7995</fax>
				<email>info@fmd.com</email>
				<url>http://www.fmd.com</url>
				<hastipemployees>false</hastipemployees>
				<policies>
					<policy>
						<number>WCAB0379-A</number>
						<status>2</status>
						<effectivedate>2007-01-01</effectivedate>
						<expirationdate>2008-01-01</expirationdate>
						<finalpolicycancellationdate>2008-03-01</finalpolicycancellationdate>
						<selfinsured>false</selfinsured>
						<tpclaimadmin>false</tpclaimadmin>
						<managedcareplan>false</managedcareplan>
						<reportclaimbycontacting>2</reportclaimbycontacting>
						<insconame>Bluetooth Insurance Group</insconame>
						<naicnumber>247</naicnumber>
						<inscoaddress1>245 Spruce Avenue</inscoaddress1>
						<inscoaddress2>Suite 2000</inscoaddress2>
						<inscocity>Chicago</inscocity>
						<inscostate>IL</inscostate>
						<inscopostalcode>60611</inscopostalcode>
						<inscophone>312-274-8791</inscophone>
						<inscocountry>United States of America</inscocountry>
						<inscoclaimaddressissame>false</inscoclaimaddressissame>
						<inscoclaimaddress1>841 South Pine</inscoclaimaddress1>
						<inscoclaimaddress2>Suite 250</inscoclaimaddress2>
						<inscoclaimcity>Chicago</inscoclaimcity>
						<inscoclaimstate>IL</inscoclaimstate>
						<inscoclaimpostalcode>60611</inscoclaimpostalcode>
						<inscoclaimcountry>United States of America</inscoclaimcountry>
						<inscoclaimurl>http://claims.blueinsgroup.com</inscoclaimurl>
						<inscoclaimrepname>Larry Walker</inscoclaimrepname>
						<inscoclaimreptitle>Claims Specialist</inscoclaimreptitle>
						<inscoclaimrepphone>312-274-4192</inscoclaimrepphone>
						<inscoclaimrepemail>claims@blueinsgroup.com</inscoclaimrepemail>
						<employerauthrepomit>false</employerauthrepomit>
						<employerauthrepaddress1>441 E Maple</employerauthrepaddress1>
						<employerauthrepaddress2>Suite 3355</employerauthrepaddress2>
						<employerauthrepcity>Chicago</employerauthrepcity>
						<employerauthrepstate>IL</employerauthrepstate>
						<employerauthreppostalcode>60611</employerauthreppostalcode>
						<employerauthrepname>Marvin McQueen</employerauthrepname>
						<employerauthreptitle>Employer Representative</employerauthreptitle>
						<employerauthrepphone>312-274-4929</employerauthrepphone>
						<employerauthrepemail>emplclaims@blueinsgroup.com</employerauthrepemail>
						<employerauthrepsignatureimg>emplbig.gif</employerauthrepsignatureimg>
						<employerauthrepwitness1>James T. Kirk</employerauthrepwitness1>
						<employerauthrepwitness2>Leonard D. Nemoy</employerauthrepwitness2>
						<managedcareorgname>Swiss Administrators of Virginia</managedcareorgname>
						<managedcareorgaddress1>200 S VanBuren</managedcareorgaddress1>
						<managedcareorgaddress2>Building 1A-007</managedcareorgaddress2>
						<managedcareorgcity>Annondale</managedcareorgcity>
						<managedcareorgstate>VA</managedcareorgstate>
						<managedcareorgpostalcode>22003</managedcareorgpostalcode>
						<managedcareorgcountry>United States of America</managedcareorgcountry>
						<managedcareorgphone>703-354-2893</managedcareorgphone>
						<managedcarerepname>Kimbrely A. Bush</managedcarerepname>
						<managedcarereptitle>Director of Managed Care</managedcarereptitle>
						<managedcarerepphone>703-354-3498</managedcarerepphone>
						<managedcarerepemail>kim.bush@sava.org</managedcarerepemail>
						<emergencyphonedoctor>312-274-1200</emergencyphonedoctor>
						<emergencyphonehospital>312-274-1300</emergencyphonehospital>
						<emergencyphoneambulance>312-274-1400</emergencyphoneambulance>
						<emergencyphonefire>312-274-1500</emergencyphonefire>
						<emergencyphonepolice>312-274-1600</emergencyphonepolice>
						<brokerorgname>Marsh USA Inc.</brokerorgname>
						<brokerorgaddress1>1500 Wall Street</brokerorgaddress1>
						<brokerorgaddress2>57th Floor Suite 5710</brokerorgaddress2>
						<brokerorgcity>New York</brokerorgcity>
						<brokerorgstate>NY</brokerorgstate>
						<brokerorgpostalcode>11101</brokerorgpostalcode>
						<brokerorgcountry>United States of America</brokerorgcountry>
						<brokerorgphone>212-230-2341</brokerorgphone>
						<brokerorgrepname>Teresa T. Fannigan</brokerorgrepname>
						<brokerorgreptitle>Director of Broker Relations</brokerorgreptitle>
						<brokerorgrepphone>212-230-2340 x135</brokerorgrepphone>
						<brokerorgrepemail>t.fannigan@marsh.com</brokerorgrepemail>
						<claimadminname>Claims-R-Us of North America</claimadminname>
						<claimadminaddress1>915 S James Street</claimadminaddress1>
						<claimadminaddress2>Suite 411</claimadminaddress2>
						<claimadmincity>Kent</claimadmincity>
						<claimadminstate>WA</claimadminstate>
						<claimadminpostalcode>98032</claimadminpostalcode>
						<claimadmincountry>United States of America</claimadmincountry>
						<claimadminphone>253-640-1399</claimadminphone>
						<claimadminrepname>Bonnie T. Parkin</claimadminrepname>
						<claimadminreptitle>Claim Coordinator</claimadminreptitle>
						<claimadminrepphone>253-640-1400</claimadminrepphone>
						<claimadminrepemail>bonnie@claimsrus.com</claimadminrepemail>
						<safetydirectorname>John Fritz Gonzales</safetydirectorname>
						<safetydirectorphone>312-274-1700</safetydirectorphone>
						<safetysupervisorname>Martin V. Wilhelm</safetysupervisorname>
						<safetysupervisorphone>312-274-1900</safetysupervisorphone>
						<pabureaucode>14087</pabureaucode>
						<virtualstickertext>Can't reach a representative? Call 800-123-HELP</virtualstickertext>
						<dateissuedposted>2006-07-01</dateissuedposted>
						<locations>
							<location>
								<jurisdictionid>NY</jurisdictionid>
								<code>WC-NY-13011</code>
								<sortid>3</sortid>
								<name>Campus Building 1A</name>
								<address1>978 Redmond Way</address1>
								<address2>Building 1A</address2>
								<city>Redmond</city>
								<state>WA</state>
								<postalcode>98010</postalcode>
								<country>United States of America</country>
								<phone>253-425-1100</phone>
								<squarefeet>1200</squarefeet>
								<floors>7</floors>
								<quantity>7</quantity>
								<mailinggroup>12</mailinggroup>
								<mailinggroupmaster>7</mailinggroupmaster>
								<repname>Howard Ashcroft</repname>
								<reptitle>MS Corporate Representative</reptitle>
								<repphone>253-425-1200</repphone>
								<repemail>h.ashcroft@msoft.com</repemail>
								<overridenamedinsured>true</overridenamedinsured>
								<overridenamedinsuredname>T-Bone International</overridenamedinsuredname>
								<overridenamedinsuredaddress1>12317 W Manchester</overridenamedinsuredaddress1>
								<overridenamedinsuredaddress2>Building A, Suite 101</overridenamedinsuredaddress2>
								<overridenamedinsuredcity>San Antonio</overridenamedinsuredcity>
								<overridenamedinsuredstate>TX</overridenamedinsuredstate>
								<overridenamedinsuredpostalcode>71230</overridenamedinsuredpostalcode>
								<overridenamedinsuredcountry>United States of America</overridenamedinsuredcountry>
								<overridenamedinsuredphone>811-182-3838</overridenamedinsuredphone>
								<hospitalname>Good Samaritan of Bellevue</hospitalname>
								<hospitaladdress1>4300 Overlake Blvd.</hospitaladdress1>
								<hospitaladdress2>Campus 1A</hospitaladdress2>
								<hospitalcity>Bellevue</hospitalcity>
								<hospitalstate>WA</hospitalstate>
								<hospitalpostalcode>98020</hospitalpostalcode>
								<hospitalphone>425-232-1995</hospitalphone>
								<wcoomit>false</wcoomit>
								<wcofficename>Workers Compensation of Washington</wcofficename>
								<wcofficeaddress1>4021 Capital Blvd.</wcofficeaddress1>
								<wcofficeaddress2>Rotunda 3A</wcofficeaddress2>
								<wcofficecity>Olympia</wcofficecity>
								<wcofficestate>WA</wcofficestate>
								<wcofficepostalcode>98501</wcofficepostalcode>
								<wcofficephone>360-867-3983</wcofficephone>
								<wcofficeemail>wco@wcowa.com</wcofficeemail>
								<overrideemergencyphonedoctor>425-421-2200</overrideemergencyphonedoctor>
								<overrideemergencyphonehospital>425-421-2300</overrideemergencyphonehospital>
								<overrideemergencyphoneambulance>425-421-2400</overrideemergencyphoneambulance>
								<overrideemergencyphonefire>425-421-2500</overrideemergencyphonefire>
								<overrideemergencyphonepolice>425-421-2600</overrideemergencyphonepolice>
								<dateissuedposted>2007-04-01</dateissuedposted>
								<overrideclaimreportingrepname>William H. DeKlotz</overrideclaimreportingrepname>
								<overrideclaimreportingrepemail>whd@claims4u.com</overrideclaimreportingrepemail>
								<overrideclaimreportingrepphone>253-640-1800</overrideclaimreportingrepphone>
								<overrideclaimreportingaddress>true</overrideclaimreportingaddress>
								<overrideclaimreportingname>Claims-4-U of South King County</overrideclaimreportingname>
								<overrideclaimreportingreptitle>Claims Administrator</overrideclaimreportingreptitle>
								<overrideclaimreportingaddress1>24180 132nd Ave. SE</overrideclaimreportingaddress1>
								<overrideclaimreportingaddress2>Suite SR201</overrideclaimreportingaddress2>
								<overrideclaimreportingcity>Covington</overrideclaimreportingcity>
								<overrideclaimreportingstate>WA</overrideclaimreportingstate>
								<overrideclaimreportingpostalcode>98072</overrideclaimreportingpostalcode>
								<overrideclaimreportingphone>253-253-2532</overrideclaimreportingphone>
								<ga_geographicalservicearea>SA-400c</ga_geographicalservicearea>
								<ny_classeescovered>All classes covered.</ny_classeescovered>
								<ny_nameofambulancedivision>South 8B</ny_nameofambulancedivision>
								<ny_nameofpoliticaldivision>South 4A</ny_nameofpoliticaldivision>
								<virtualstickertext>Repeat Injury? Call 800-456-COMP</virtualstickertext>
							</location>
						</locations>
					</policy>
				</policies>
			</insured>
		</insureds>
	</firm>
</dynaform.net>
