R2004-168 AUTHORIZING EMPLOYEE GROUP TERM LIFE INSURANCE COVERAGE

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, � � , MUTUAL OF OMAHA INSURANCE COMPANY [ ] UNITED OF OMAHA LIFE INSURANCE COMPANY [ ] Mutual of Omaha Plaza m Omaha,NE 68175 Muruat�`Om�xa Home Office Use Only Policy Number(s): Group Insurance Application Applicant(Full LegalName) City of Decatur, IL ' (the Policyholder) ' Address 1 Gar� K. Anderson Plaza CitY Decatur State IL Zip 6252� Requested Effective Date: 11/1/2004 , subject to our acceptance of this application and payment of premium on or before such date. Coverase(s)beinQ anulied for: [✓f Life [�AD&D ❑ Short Term Disability [�.ife and Dependent Life ❑AD&D and Dependent AD&D ❑ Long Term Disability Active at work reQuirement: An employee must meet an Active at W rk requirement to become insured. Will all proposed insureds meet the Active at Work requirement? ❑ Yes �No If"No," please provide the name of the individual,date of birth,date of disability or confinement and nature of disability or co�nernent on a separate page. Certain states have enacted legislation that requires insurers to provide specific coverage for people residing in their states. Do you have employees residing in or working in other states? ❑Yes[v]'No If"Yes,"which states: Financial Risk(If"Yes," to any part,please explain below) 1. Has the applicant ever filed for bankruptcy? ❑ Yes [v�No 2. Does the applicant anticipate ceasing or materially reducing active business operations? ❑Yes �]/'No Explanation: Application is made on the basis of the proposal, any available experience data and the information contained in this application. The applicant signing below agrees to accept the terms and provisions of the Master Policy for the coverages applied for above. Insurance will become effective on the requested effective date shown above, unless we send written notice of a different effective date. If this application is not approved by an o�cer at the Home Off`ice of the underwriting company,no insuranae is in effect at any time and any advance payment received will be retumed. This application is submitted with the following advance payment$ 4476.05 Fraud Warning - Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties. For Applican • Name of Broker, agent and/or insurance agency soliciting this coverage: By �e o R.� i A . T�v� (Signa e) _ �?(;� �"�-�v (Ti e) 11 � a �/ (Date) 10634GA-EZ 04 [L/AD/D]