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' :- � ' �� Aii�IENDATORY RIDER <br /> ATTACHED TO AND MADE A PART OF POLICY NUMBER: F177803 <br /> Policyholder: CITY OF DECATUR EMPLOYEES <br /> Effective Date of Change: OCTOBER 18, 1999 <br /> The above Policy is amended as follows: <br /> The Class Description as shown on the Application for Group Insurance to Fort <br /> Dearborn Life Insurance Company is hereby amended to include the following: <br /> Class Description Benefit Amount <br /> 2-1 City Manager Basic Life/ADD: <br /> Two times Basic Annual <br /> Salary rounded to the nearest <br /> $1,000 to a maximum of <br /> 250,000 <br /> Supplemental Life: <br /> Benefits can be elected in <br /> $10,000 increments to <br /> maximum of$100,000 <br /> The combined Basic and Supp(emental Life Benefits cannot exceed the <br /> combined amount of$350,000. <br /> All other conditions and provisions remain unchanged. <br /> FORT DEARBORN LIFE INSURANCE COMPANY <br /> /�,� , <br /> C/ <br /> President <br /> Accepted <br /> /�--3d_ �` '�� <br /> Policcholdzr Date <br /> 137-BEIA <br />