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Signature <br /> Crystal Schunng <br /> Sales Representative Signature of Authorized Purchaser <br /> 843 815-639-1559 <br /> District Prone&FAX Numbers Print Name <br /> Rick Semonis <br /> Producer Representative Title <br /> First Mid Insurance Group Agency#000608167 <br /> Producer Firm Date <br /> 230 SW Adams Street <br /> Suite 100 <br /> Peoria, IL 61602 <br /> Producer Address <br /> 309-687-4735 <br /> Producer Phone&FAX Numbers <br /> rsemonis@firstmid.com <br /> Producer Email Address <br /> 37-1272270 <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 /> IL GEN ASO VBD BPA(Rev.06.24)Blue Cross and Blue Shield of Illinois,a Division of Health Care Service Corporation,a Mutual <br /> Legal Reserve Company,an Independent Licensee of the Blue Cross and Blue Shield Association 13 <br />