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ASO <br /> Benefit Program Application ("ASO BPA") <br /> Applicable to Administrative Services Only(ASO) Group Accounts <br /> administered by Blue Cross and Blue Shieid of Iilinois,a Division of Health Care Service Corporation, <br /> a Mutual Legal Reserve Company,hereinafter referred to as"Claim Administrator"or"HCSC" <br /> Group Status: Renewing ASO Account <br /> If former HCSC Insured Group converting to ASO, on what basis? Not applicable <br /> Employer Account Number(6-digits): 022346 Group Number(s): P22346, Section Number(s): 0100, <br /> P22347, P2348, P22349 0200, 0300, 0400, 8888 <br /> Legal Employer Name: City of Decatur <br /> (Specify the employer or the employee trust applying for coverage. Names of subsidiary or affiliated companies to be <br /> covered must also be included. AN EMPLOYEE BENEFIT PLAN MAYNOT BE NAMED.) <br /> ERISA Regulated Group Health* Plan: ❑Yes � No <br /> If Yes, is your ERISA Plan Year a period of 12 months beginning on the Anniversary Date specified below? ❑Yes ❑ No <br /> If no, please specify your ERISA Plan Year": Beginning Date_/_/_ End Date_/_/_ (month/day/year) <br /> ERISA Plan Administrator*: Plan Administrator's Address: <br /> If you maintain that ERISA is not applicable to your group health plan, please give legal reason for exemption: <br /> Non-Federal Governmental Plan (Public Entity) ; if applicable, specify other: <br /> Is your Non-ERISA Plan Year a period of 12 months beginning on the Anniversary Date specified below? �Yes ❑No <br /> If no, please specify your Non-ERISA Plan Year: Beginning Date_/ / End Date_/ / (month/day/year) <br /> For more information regarding ERISA, contact your Legal Advisor. <br /> *All as defined by ERISA and/or other applicable law/regulations <br /> Effective Date of Coverage: 01/01/2016 Anniversary Date: Month/Year 01 /2017 <br /> ACCOUNT INFORMATION <br /> � NO CHANGES ❑ SEE ADDITIONAL PROVISIONS <br /> Standard Industry Code(SIC): 9111 Employer ldentification Number(EIN): 37-6001308 <br /> Address: #1 Gary K.Anderson Plaza <br /> City: Decatur State: IL Zip: 62523 <br /> Administrative Contact: Linda Mendenall Title: Group Administrator <br /> Email Address: Imendenall@decaturil.gov Phone Number: 217- Fax Number: 217-424-2717 <br /> 424-2803 <br /> Subsidiaries: <br /> A�liated Companies: <br /> (If Affiliated Companies listed above are to be covered,a separate"Addendum to the Benefit Program Application Regarding Affiliated Companies�must <br /> be completed,signed by the Employer's authorized representative,and attached to this Benefit Program Application.) <br /> Blue Access for Employers (BAE) Contact: Linda Mendenall <br /> (The BAE Contact is the Employee of the Account authorized by the Employer to access and maintain its account in BAE.) <br /> Email Address: Imendenall@decaturil.gov Phone Number: 217-424- Fax Number: 217-424-2717 <br /> 2803 <br /> SCHEDULE OF ELIGIBILITY <br /> � NO CHANGES ❑ SEE ADDITIONAL PROVISIONS <br /> HCSC IL GEN ASO BPA(Rev. 5.15) page 1 <br />