R2015-120 AUTHORIZING CITY MANAGER TO SIGN AGREEMENT Bluecross Blueshield of Illinois

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1. Eligible Person means: � A full-time employee of the Employer. ❑ A full-time employee who is a member of: (name of union) � Other: Retired per labor agreement or admin policy 2. Full-Time Employee means: � A person who is regularly scheduled to work a minimum of 30 hours per week and who is on the permanent payroll of the Employer. ❑ Other: 3. The Effective Date of termination for a person who ceases to meet the definition of Eligible Person: � The date such person ceases to meet the definition of Eligible Person. ❑ The last day of the calendar month in which such person ceases to meet the definition of an Eligible Person. ❑ Other: 4. Civil Union Partners covered: i. �Yes. Check "Yes" if Employer is an Illinois county, municipality, the State of Illinois, subject to the Illinois School Code, a church plan or other non-ERISA plan. For such Employers, a Civil Union Partner and his or her dependents are automatically eligible to enroll for coverage and, once enrolled, eligible for continuation of coverage as described in the Employer's Plan. Skip to item 5 below. ii. For all other Employers, ❑Yes ❑ No If yes: A Civil Union Partner and his or her dependents are eligible to enroll for coverage. If yes, are Civil Union Partners and his or her dependents eligible for continuation of coverage? ❑Yes ❑ No The Employer is responsible for providing notice of possible tax implications to those Covered Employees with coverage for Civil Union Partners. 5. Domestic Partners covered: ❑ Yes � No(skip to Question 6) If yes: A Domestic Partner is eligible to enroll for coverage. If yes, are Domestic Partners eligible for continuation of coverage? ❑ Yes ❑ No Ifyes, are dependents of Domestic Partners eligible to enroll for coverage? ❑Yes ❑ No Ifyes, are dependents of Domestic Partners eligible for continuation of coverage? ❑Yes ❑ No The Employer is responsible for providing notice of possible tax implications to those Covered Employees with coverage for pomestic Partners. 6. The Limiting Age for covered children is Twenty-six (26) years, regardless of presence or absence of a child's financial dependency, residency, student status, employment, marital status or any combination of those factors. If Employer is an Illinois county, municipality, the State of Illinois, or subject to the Illinois School Code, this Limiting Age is extended to thirty(30)years, for unmarried eligible military personnel as described in the Employer's Plan. To cover dependent children age twenty-six (26) and over other than unmarried eligible military personnel described above, you may select and complete option i. or ii. below: i. ❑The Limiting Age for covered children age twenty-six(26)or over, ❑who are unmarried ❑ regardless of marital status, is years. (Twenty-seven (27)through thirty(30) are the available options.) ii. ❑The Limiting Age for covered children who are full-time students and age twenty-six(26) or over, ❑who are unmarried ❑ regardless of marital status, is years(Twenty-seven (27)through thirty(30)are the available options.) Coverage based on the Limiting Age(s)elected above terminates on: � The birthday on which the Limiting Age is reached. ❑ The last day of the calendar month in which the Limiting Age is reached. However, such coverage shall be extended in accordance with any applicable federal or state law. HCSC IL GEN ASO BPA(Rev. 5.15) page 2