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. �, �, �,_ � ��� <br /> RELIANCE STANDARD LIFE INSURANCE COMPANY <br /> Philadelphia, Pennsylvania <br /> GROUP POLICY NUMBER: GL 143071 POLICY EFFECTIVE DATE: November 1, 2007 <br /> POLICY DELIVERED IN: Illinois ANNIVERSARY DATE: November 1 st in each year <br /> Application is made to us by: City of Decatur Illinois <br /> This Application is completed in duplicate, one copy to be attached to your Policy and the other returned to us. <br /> It is agreed that this Application takes the place of any previous application for your Policy. <br /> Signed at �C,A(UQ. ��.���Jp15 this 3 0 th day of November, 2 0 0 7 <br /> Policyholder. Cf4 OF T l,�►� s Agent: �HIJ}CE� l D��OUN NIAI.RCNOWy�� <br /> By: <br /> Steve G I[18X1Signature) (LicensedResidentAgeM) <br /> City Manager <br /> ATTES y (Title) <br /> � � <br /> -��.. `� c=t'/�l%� <br /> City Clerk Please sign and retum. <br /> LRS-6422-A Ed. 3/82 I IIIIIIIIIIIIIIIIIIIIIIII <br />