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Benefit Program Application ("ASO BPA") <br /> Applicable to Administrative Services Only(ASO)Group Accounts <br /> administered by Blue Cross and Blue Shield of Illinois,a Division of Health Care Service Corporation, <br /> a Mutual Legal Reserve Company,an Independent Licensee of the Blue Cross and Blue Shield Association,hereinafter referred to as"Claim <br /> Administrator"or"BCBSIL" <br /> Group Status: Renewing ASO Account <br /> Employer Account Number(6-digits): 022346 Group Number(s): P22346, PE4337, PJ1005, PJ1009 <br /> Section Number(s): 0100 0200 0300 0400 0410 0500 0510 0550 0600 0700 0800 0810 8888 <br /> Legal Employer Name: City of Decatur <br /> (Specify the Employer or the employee trust applying for coverage. Names of subsidiary or affiliated companies to be <br /> covered must also be named below. AN EMPLOYEE BENEFIT PLAN MAYNOT BE NAMED.) <br /> ERISA Regulated Group Health Plan*: ❑Yes ® No <br /> Is your ERISA Plan Year"a period of 12 months beginning on the Effective Date of Coverage specified below? ❑Yes <br /> If not,please specify your ERISA Plan Year*: Beginning Date / / End Date /_/ (month/day/year) <br /> ERISA Plan Administrator*: <br /> Plan Administrator's Address: <br /> If you maintain that ERISA is not applicable to your group health pian,give legal reason for exemption: <br /> Non-Federal-Municipality ; if applicable,specify other: <br /> Is your Non-ERISA Plan Year*a period of 12 months beginning on the Anniversary Date specified below? ®Yes <br /> If not, please specify your Nan-ERISA Plan Year*: Beginning Date / / End Date_I I (month/day/year) <br /> For more information regarding ERISA,contact your Legal Advisor. <br /> *Ail as defined by ERISA and/or other applicable law/regulations <br /> Effective Date of Coverage:(Monthfday/Year) 01 /0112025 <br /> Anniversary Date: (MonthlDay/Year) 0110112026 <br /> Retiree-Only Plan(s)Identification: <br /> For more information regarding Retiree-only plans,contact your Legal Advisor. <br /> Do you have one or more Retiree-only plan(s)2 ❑Yes ® No <br /> If yes, please provide Benefit Agreement number,or group and section numbers of the Retiree-only plan(s): <br /> Account Information NO CHANGES Ej SEE ADDITIONAL PROVISIONS <br /> Standard industry Code(SIC): 9111 Employer Identification Number(EIN): 376001308 <br /> Address: #1 Gary K.Anderson Plaza <br /> City: Decatur State: IL ZIP: 62523-1005 <br /> Administrative Contact: Ruby James Title: City Treasurer and Director of Finance <br /> Email Address: rjames@decaturil.gov Phone Number: (217)424-2702 Fax Number: (217) <br /> 424-2717 <br /> Wholly Owned Subsidiaries to be covered: N/A <br /> Affiliated Companies to be covered: N/A Employer Identification Number(EIN): N/A <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)Slue 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 1 <br />