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The Employer acknowledges that if any producer/consultant acts on its behalf for purposes of purchasing services in <br /> connection with the Employer's Plan under the Administrative Services Agreement to which this ASO BPA is <br /> attached, the Claim Administrator may pay the Employer's producer/consultant a commission and/or other <br /> compensation in connection with such services under the Agreement. If the Employer desires additional information <br /> regarding commissions and/or other compensation paid the producer/consultant by the Claim Administrator in <br /> connection with services under the Agreement, the Employer should contact its producer/consultant. <br /> Additional Provisions: Effective 1.1.2018 adding Naturally Slim and Protect My ID and COBRA administration <br /> Updated contact information adding Gregg Zientara and Jenifer McCoskex <br /> Adding group section 0500 Active Civic Center and 0900 Retired Civic Center to plan P22347. (BA 0008) <br /> adding MD Live .45 PEPM cost <br /> Signature <br /> Holly Little <br /> Sales Representative Signature of Authorized Purchaser <br /> 843 815-639-7330 <br /> �rn G I m sore <br /> District Phone&FAX Numbers Print Name <br /> Rick Semonis <br /> -i-{-t,{ M�U't�e'' <br /> Producer Representative Title <br /> SBSi Semonis, a division of J. L. Hubbard <br /> Insurance and Bonds, Inc. <br /> Producer Firm Date <br /> 4530 N. University Ave., Peoria, IL 61614 <br /> Producer Address <br /> 309-687-6020(P) 217-233-3332(F) <br /> Producer Phone&FAX Numbers <br /> rsemonis@jlhubbard.com <br /> Producer Email Address <br /> 37-1126488 <br /> Tax I.D. No. <br /> Proprietary and Confidential Information of Claim Administrator <br /> Not for use or disclosure outside Claim Administrator,Employer,their respective affiliated companies and third party representatives,except <br /> with written permission of Claim Administrator. <br /> HCSC IL GEN ASO BPA(Rev.08/17) A Division of Health Care Service Corooration,a Mutuaf Legal Reserve Company, 8 <br /> an Independent Licensee of the Blue Cross and Blue Shield Association <br />