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, 0 � ' <br /> ASO <br /> Benefit Program Application <br /> Applicable to Administrative Services Only (ASO) Group Accounts <br /> Employer Account Number(6-digits): 022346 <br /> Employer Group Number(s): P22346, P22347, P22348, P22349, 022346 <br /> Section Number(s): <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 also <br /> be included. AN EMPLOYEE BENEFIT PLAN MAY NOT BE NAMED) <br /> Address: #1 Gary K. Anderson Plaza <br /> City. Decatur State: IL Zip: 62523-1196 <br /> Standard Industry Code (SIC): 9111 <br /> Subsidiaries: None <br /> Affiliated Companies: None <br /> (If Affiliated Companies to be covered are listed above, a separate"Addendum to the Benefit Program Application Regarding Affiliated <br /> Companies"must be completed,signed by the Employer's authorized representative,and attached to this Benefit Program Application.) <br /> Administrative Contact: Deborah L. VanZant Phone Number: 217-424-2803 Fax Number. 217-424-2717 ' <br /> Email Address: ' <br /> dlvanzant@decaturnet.org <br /> �'lan Administrator: Barry J. Leonard ERISA Plan Year: ends 12/31 <br /> ��ffective Date of Coverage: 01/01/2008 Anniversary Date: 01/01/2009 <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 /> 3. The Effective Date of termination for a person who ceases to meet the definition of Eligible Person: <br /> � The date such person ceases to meet the definition of Eligible Person. <br /> ❑ The last day of the calendar month in which such person ceases to meet the definition of an Eligible Person. <br /> ❑ Other: <br /> 4. Domestic Partners covered: ❑ Yes � No <br /> If yes: A Domestic Partner, as defined in the Plan, shall be considered eligible for coverage. The Employer is responsible for <br /> providing notice of possible tax implications to those Covered Employees with Domestic Partners. <br /> �A-10-4 HCSC IL Rev. 09/12/07 (On-line Version) page 1 <br />