R2024-342 Resolution Authorizing Agreement and Amendment with BlueCross BlueShield of Ilinois for Administration of the City Group Health Benefit Plan for Calendar Year 2025

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(Affiliated Companies must be required or permitted to be aggregated per IRS Guidelines,Employer hereby confirms that Employer,Subsidiaries and Affiliates are treated as a single employer under Internal Revenue Code Section 414(b),or(c),or(m)or(o),or under applicable law.) Blue Access for Employers"'("BAEsM")Contact: Brian Hastings (The SAE Contact is the Employee authorized by the Employer to access and maintain the Employer's account in SAE.) Email Address:bhastings@decaturil.gov Phone Number: (217)424-2843 Fax Number: (217)424- 2717 ®The Employer or other company listed in this BPA is a public entity or governmental agency/contractor _11�roducer of . NO CHANGES E SEE ADDITIONAL PROVISIONS Effective: 01/0112025 If applicable, the below-named producer(s) or agency(ies) is/are recognized as Employer's Producer of Record (POR)to act as a representative in negotiations with and to receive commissions from BCBSIL, Claim Administrator's corporate subsidiaries, as applicable, for procuring Claim Administrator's claims administration services for Employer's employee benefit program(s). This statement rescinds any and all previous POR appointments for the Employer. The POR is authorized to perform membership transactions on behalf of the Employer. This appointment will remain in effect until withdrawn or superseded in writing by the Employer. Producer/Consultant Compensation: The Employer acknowledges that if its POR acts on its behalf for purposes of purchasing services in connection with the Employer's Plan under the Administrative Services Agreement to which this ASO BPA is attached,the Claim Administrator may pay the Employer's POR a commission and/or other compensation in connection with such services under the Administrative Services Agreement. If the Employer desires additional information regarding commissions and/or other compensation paid to the POR by the Claim Administrator in connection with services under the Administrative Services Agreement,the Employer should contact its POR. Are commissions to be paid? ❑Yes ® No Producer or Agency to whom commissions are to be paid": Illinois Producer#:(nine digits) NPN: Address: City: State: Phone: Fax: Is Producer/Agency appointed with BCBSIL?❑Yes ❑ No Commissions: ❑ PCPM$ Does a Monthly Cap Apply❑Yes ❑ No $ (If cap is annual, divide by twelve) ❑ Fiat$ Does a Monthly Cap Apply ❑Yes ❑ No $ (If cap is annual, divide by twelve) ❑Percentage of Stop Loss: % ADDITIONAL COMMISSIONS: *The Producer or agency name(s)above to whom commissions are to be paid must exactly match the name(s)on the appointment application(s). ,Schedule of Eligibility NO CHANGES SEE ADDITIONAL - • • Employer has made the following eligibility decisions: 9. 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) ❑ A part-time employee of the Employer. ❑ A retiree of the Employer. Define criteria: ® Other: Retired per labor agreement or admin policy Are any classes of employees to be excluded from coverage? ❑Yes ® No 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. IL GEN ASO VBD BPA(Rev.06.24)Blue Cross and Blue Shield of Illinois,a Division of Health Care Service Corporation,a Mutual Legal Reserve Company,an Independent Licensee of the Blue Cross and Blue Shield Association 2