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� PROXY �, <br />, The undersigned hereby appoints the Board of Directors of Health Care Service Corporation, a Mutual Legal Reserve Company, I <br /> or any successor thereof("HCSC"), with full power of substitution, and such persons as the Board of Directors may designate by <br /> m r f H II <br /> resolution, as the undersigned's proxy to act on behalf of the undersigned at all meetings of ine be s o CSC (and at a <br /> meetings of inembers of any successor of HCSC) and any adjournments thereof, with full power to vote on behaff of the <br /> undersigned on all matters that may come before any such meeting and any adjournment thereof. The annual meeting of <br /> members shall be held each year in the corporate headquarters on the last Tuesday of October at 12:30 p.m. Special meetings <br /> of inembers may be called pursuant to notice mailed to the member not less than thirty (30) nor more than sixty (60) days prior <br /> to such meetings. This proxy shall remain in effect until revoked in writing by the undersigned at least twenty (20) days prior to <br /> an meetin of inembers or b attendin and votin in erson at an annual or s eciat meetin of inembers. <br /> Y 9 Y 9 9 P Y p 9 <br /> Group No.: P22346 By: <br /> P22347 <br /> P22348 ,�,/ <br /> P22349 �,¢�it/ � /��� C/t�y <br /> Print Signer's Name Here <br /> � L ` /�dh/►9G'� <br /> Sign e and Title <br /> Group Name: City of Decatur, Illinois <br /> Address: #1 Gary K. Anderson Plaza <br /> City: Decatur State: IL Zip Code: 62523 <br /> Dated this day of <br /> Month Year <br /> HCSC IL GEN ASO BPA Rev. 9.1.10(On-line Version) page 11 <br />