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�o <br /> Benefit Program Application <br /> (Applicable to ASO Graup Accounts) <br /> Employer Group Number(s): ��2844/po6856 Section Number(s): oloo <br /> Empioyer Name: cxty of Deca�u� <br /> (Speci',ihe employer,the employee trust or the assoriation applying tor coverage. Names of subsidiary or affiliated companies to be coverod must also be inctuded. <br /> AN EMPLOYEE BENEFIT PLAN MAYNOT BE NAMED� <br /> Employer ldentification Number(EIN): <br /> Address: #]. cxvi;c center P1aza City: Decatur State: IL ZiP:_6252� <br /> Subsidiaries: <br /> Affiliated Companies: <br /> Administrative Contact: Mrr serry �auex Phone Number: (217) 424-2803 <br /> Effective Date of Coverage: �-�-�Q�-��� Anniversary Date: l�/O1/98 <br /> SCHEDULE OF EL(GIBILITY <br /> 1. Eligible Person means: <br /> � A full-time employee of the Err�ployer. <br /> ❑ A full-time empioyee who is a member of: <br /> (name of union or association) <br /> �.x1 Other:_ Ret�,rees who are othexwise e7.igzble ,per terms of City laboY ac�reeme»t or <br /> 2. Full-Time Employee means: administrative policy. <br /> �l A person who is regularly scheduled to work a minimum of 30 hours per week and who is actively at work <br /> end on the permanent payroll of the Employer. <br /> ❑ Other: <br /> 3. The Effective Date of termination for a person who ceases to meet the definition of Eligible Person: <br /> �l The date such person ceases to meet the definition of Eligible Person. <br /> ❑ The last day of the calendar month in which such person ceases to meet the definition of an Eligible Person. <br /> ❑ Other: <br /> 4. Limiting Age: <br /> �xl The limiting age for covered unmarried children is 2�_. <br /> ❑ The limiting age for covered unmarried children is ; age if a full-time student. <br /> ❑ Other: <br /> Termination of coverage upon reaching the Limiting Age: <br /> � Coverage is terminated on the birthday. <br /> � Coverage is terminated on the last day of the month in which the limiting age is reached. <br /> 5. The Eligibility Date for a person who becomes an Eligible Person after the Effective Date of the Employer's health <br /> care plan: <br /> � The date of employment. <br /> ❑ The day of employment. <br /> ❑ The day of the month following month(s) or days of employment. <br /> Ci The day of the month following the date of employment. <br /> ❑ Other: <br /> GA-10-4 HCSC Rev.6/96 page 1 <br />