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PROXY <br /> The undersigned hereby appoints the Board of Directors of Health Care Service Corporation, a Mutual Legal Reserve <br /> Company, or any successor thereof("HCSC"),with full power of substitution, and such persons as the Board of Directors <br /> may designate by resolution,as the undersigned's proxy to act on behalf of the undersigned at all meetings of members of <br /> HCSC (and at all meetings of members of any successor of HCSC) and any adjournments thereof,with full power to vote <br /> on behalf of the undersigned on all matters that may come before any such meeting and any adjournment thereof. The <br /> annual meeting of members is scheduled to be held each year in the HCSC corporate headquarters on the last Tuesday of <br /> October at 12:30 p.m. Special meetings of members may be called pursuant to notice provided to the member not less than <br /> thirty (30) nor more than sixty (60) days prior to such meetings. This proxy shall remain in effect until either revoked in <br /> writing by the undersigned at least twenty(20)days prior to any meeting of members or by attending and voting in person <br /> at any annual or special meeting of members. <br /> From time to time, HCSC pays indemnification or advances expenses to its directors, officers, employees or agents <br /> consistent with HCSC's bylaws then in force and as otherwise required by applicable law. <br /> ā¯‘Intentionally left blank by the Employer <br /> P22346, By: <br /> Group No.: PE4337, <br /> PJ 1005, <br /> PJ1009 <br /> Print Signer's Name Here <br /> Signature and Title <br /> Group Name: City of Decatur <br /> Address: #1 Gary K.Anderson Plaza <br /> City: Decatur State: IL ZIP: 62523.1005 <br /> Dated this day of <br /> Month Year <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 14 <br />