R2017-115 Agreement BlueCross BlueShield for Administration of City Group Health Benefit Plan for 2018

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Benefit Program Application ("ASO BPA") Applicable to Administrative Services Only(ASO)Group Accounts administered by Blue Cross and Blue Shield of Illinois,a Division of Health Care Service Corporation, a Mutual Legal Reserve Company,hereinafter referred to as"Claim Administrator"or"HCSC" Group Status: Renewing ASO Account Group Number(s): P22346, Section Number(s): 0100, Employer Account Number(6-digits): 022346 P22347, P22348, P22349, 0200, 0300, 0400, 0550, 0900 PE4337 8888 Legal Employer Name: City of Decatur (Specify the Employer or the employee trust applying for coverage. Names of subsidiary or affiliated companies to be covered must also be named below. AN EMPLOYEE BENEFIT PLAN MAY NOT BE NAMED.) ERISA Regulated Group Health Plan*: ❑Yes ® No Is your ERISA Plan Year*a period of 12 months beginning on the Anniversary Date specified below?❑Yes If not, please specify your ERISA Plan Year*: Beginning Date_/_/_ End Date_/ / (month/day/year) ERISA Plan Administrator*: Plan Administrator's Address: If you maintain that ERISA is not applicable to your group health plan, give legal reason for exemption: Select legal reason ; if applicable, specify other: Is your Non-ERISA Plan Year*a period of 12 months beginning on the Anniversary Date specified below? ®Yes If not, please specify your Non-ERISA Plan Year*: Beginning Date_/ / End Date_! / (month/day/year) For more information regarding ERISA,contact your Legal Advisor. *All as defined by ERISA and/or other applicable law/regulations Effective Date of Coverage: (Month/DayNear) 01 /01 /2018 Anniversary Date: (Month/DayNear) .al /01 /2019 Account Information NO CHANGES SEE ADDITIONAL PROVISIONS Standard Industry Code(SIC): 9111 Employer Identification Number(EIN): 37-6001308 Address: #1 Gary K. Anderson Plaza City: Decatur State: IL ZIP: 62523 Administrative Contact: Gregg Zientara Title: Group Administrator Email Address: gzientara@decaturil.gov Phone Number: 217-424-2702 Fax Number: 217-424- 2717 Wholly Owned Subsidiaries: Affiliated Companies: (If Subsidiaries or Affiliated Companies listed above are to be covered,Employer hereby confirms that Employer and the listed Subsidiaries and/or Affiliates are treated as a single employer under Internal Revenue Code Section 414(b),(c)or(m).) Blue Access for Employers(BAE) Contact: Jenifer McCoskey (The BAE Contact is the Employee authorized by the Employer to access and maintain the Employer's account in BAE.) Email Address:jmccoskey@decaturil.gov Phone Number: 217-424- Fax Number: 217-424-2717 2803 ❑The Employer or other company listed in this BPA is a public entity or governmental agency/contractor Schedule of Eligibility NO CHANGES SEE ADDITIONAL PROVISIONS Employer has made the following eligibility decisions: 1. Eligible Person means: ®A full-time employee of the Employer. ❑A full-time employee of the Employer who is a member of. (name of union) ® Other: Retired per labor agreement or admin policy Are any classes of employees to be excluded from coverage? ❑Yes ❑ No If yes, please identify the classes and describe the exclusion: Proprietary and Confidential Information of Claim Administrator Not for use or disclosure outside Claim Administrator,Employer,their respective affiliated companies and third party representatives,except with written permission of Claim Administrator. HCSC IL GEN ASO BPA(Rev.08/17) A Division of Health Can:Service Corporation,a Mutual Legal Reserve Company, 1 an Independent Licensee of the Blue Cross and Blue Shield Association