R2007-238 AUTHORIZING AGREEMENT WITH BLUE CROSS BLUE SHIELD OF ILLINOIS

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5� Limiting Age for covered unmarried children: � The limiting age for covered unmarried children is 23. ❑ The limiting age for covered unmarried children is ; age if a full-time student. ❑ Other: Termination of coverage upon reaching the Limiting Age: � Coverage is terminated on the birthday. ❑ Coverage is terminated on the last day of the month in which the limiting age is reached. 6. The Eligibility Date for a person who becomes an Eligible Person after the Effective Date of the Employer's health care plan: � The date of employment. ❑ The day of employment. ❑ The day of the month following month(s) or days of employment. ❑ The day of the month following the date of employment. ❑ Other: 7 Enrollment: Special Enrollment: An Eligible Person may apply for coverage, Family coverage or add dependents within thirty-one (31) days of a qualifying event if he/she did not apply prior to his/her Eligibility Date or when eligible to do so. Such person's Coverage Date, Family Coverage Date, and/or dependent's Coverage Date will be the effective date of the qualifying event or, in the event of Special Enrollment due to termination of previous coverage, the date of application of coverage. Late Enrollment: An Eligible Person may apply for coverage, Family coverage or add dependents if he/she did not apply prior to his/her Eligibility Date or did not apply when eligible to do so. Such person's Coverage Date, Family Coverage Date, and/or dependenYs Coverage Date will be a date mutually agreed to by the Claim Administrator and the Employer. Open Enrollment� � Yes ❑ No An Eligible Person may apply for coverage, Family coverage or add dependents if he/she did not apply prior to his/her Eligibility Date or did not apply when eligible to do so, during the Employer's Open Enrollment Period. • Specify Open Enroliment Period: Three Tier PPO Programs only: Group Numbers: P22347-P22348-P22349 - Bi-Annually Such person's Coverage Date, Family Coverage Date, and/or dependent's Coverage Date will be a date mutually agreed to by the Claim Administrator and the Employer. Such date shall be subsequent to the Open Enrollment Period. 8. Extension of benefits due to Temporary Layoff, Disability or Leave of Absence: Temporary Layoff: 0 days Disability: 0 days Leave of Absence: 0 days However, benefits shall be extended for the duration of an Eligible Person's leave in accordance with any applicable federal or state law. ASO STATUS: 1 Group Status: New ASO Account 2 If a former HCSC Insured Group is converting to ASO, on what basis? Basis: Select from Pull Down GA-10-4 HCSC IL Rev. 09/12/07(On-line Version) page 2