Laserfiche WebLink
AS <br /> 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, hereinafter referred to as"Claim Administrator"or"HCSC" <br /> Employer Account Number(6-digits): 022346 <br /> Employer Group Number(s): P22346 - P22347- P22348 - P22349 <br /> Section Number(s): 0100-0200-0300-044- 8888 <br /> Employer Name: City of Decatur, Illinois <br /> (Specify the employer or the employee trust applying for coverage. Names of subsidiary or affiliated companies to be covered must <br />� also be included. AN EMPLOYEE BENEFIT PLAN MAYNOT BE NAMED.) <br /> Address: #1 Gary K. Anderson Plaza <br /> City: Decatur State: IL Zip: 62523 <br /> Standard Industry Code (SIC): 0111 Employer ldentification Number(EIN): 37-6001308 <br /> Subsidiaries: <br /> Affiliated Companies: <br /> (If Affiliated Companies to be covered are listed above,a separate"Addendum to the Benefit Program Application Regarding A�liated <br /> Companies"must be completed,signed by the Employer's authorized representative,and attached to this Benefit Program Application.) <br /> Administrative Contact: Linda Mendenall Phone Number: 217-424- Fax Number: 217-424-2717 <br /> 2803 <br /> Title: Group Adm Email Address: <br /> Imendenall@decaturil.gov <br /> Blue Access for Employers (BAE) Contact: Linda Phone Number: above Fax Number: above <br /> Mendenall <br /> (The BAE Contact is the Employee of the Account authorized by the Employer to access and maintain its Email Address: above <br /> account via BAE.) <br /> ERISA Plan: � Yes ❑ No If yes, specify ERISA Plan Year: 1/1/2011 <br /> ERISA Plan Administrator: City of Decatur Plan Administrator's address: above <br /> Effective Date of Coverage: 1/1/2011 Anniversary Date: 1/1/2012 <br /> SCHEDULE OF ELIGIBILITY <br /> 1. Eligible Person means: <br /> � A full-time employee of the Employer. <br /> ❑ A full-time employee who is a member of: <br /> (name of union) <br /> � Other: Retirees per labor agreement or admin policy <br /> 2. Full-Time Employee means: <br /> � A person who is regularly scheduled to work a minimum of 30 hours per week and who is on the permanent <br /> payroll of the Employer. <br /> ❑ Other: <br /> HCSC IL GEN ASO BPA Rev. 9.1.10(On-line Version) page 1 <br />