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' POLICYHOLDER INFORMATION <br /> Legal Name of Policyholder City of Decatur, Illinois <br /> (Must match name on application) <br /> Post Office Box Address 1 Gary K. anderson PlaZa <br /> Street Address and Suite n I <br /> City, State, Zip Code Decatur, IL 62523 <br /> COUntY Macon <br /> Phone Number 217-424-2803 <br /> Fax Number 217-424-2717 <br /> E-mail Address �bleonard@decaturnet.or� <br /> Contact Person and Title J. Barry Leonard, Risk Manager <br /> Claims Contact Person (if different) J. Barry Leonard, Risk Manager <br /> Premium Contact Person (if different) Deborah VanZant, Risk Management Assistant <br /> Tax Identification Number 37-6001308 <br /> Nature of Business/SIC Code Municipality <br /> COVERAGE(S) <br /> L�Life/AD&D ❑ Dental ❑ STD ❑ LTD ❑ Medical <br /> C�%oluntary Life ❑ Voluntary LTD ❑ Voluntary STD ❑ Voluntary Dental <br /> ❑ RENEWAL NOTICE <br /> How many days are required for Renewa!Notice? ❑ 30 Days �60 Days <br /> 10/27/04 2 of 5 <br />