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,�- , <br /> � �� <br /> Benefit Program Application <br /> (Applicable to ASO Group Accounts) <br /> Employer Group Number(s): 992844/P06856 Section Number(s): 0100 (for both #' ) <br /> Employer Name: Ci ty of DeCatur <br /> (Speciy the employer,the employea trust or the association applying for coverage. Names of subsidiary or aNiliated companies to be covered must also be inGuded. <br /> AN EMPIOYEE BENEFIT PLAN MAY NOT BE NAMED� <br /> Employer ldentifi�ation Number(E W): <br /> Address: #1 C�viC Center Pla �;�y: Decatur State: IL Zip; 62523 <br /> Subsidiaries: <br /> Affiliated Companies: <br /> Administrative Contact: Mr. Jerry Bauer Phone Number: <br /> Effective Date of Coverage: 1� 1 - Anniversary Date: 11/O1/97 <br /> SCHEDULE OF ELIGIBILITY <br /> 1. Eligible Person means: <br /> � A full-time employee of the Employer. <br /> ❑ A full-time employee who is a member of: <br /> (name of union or association) <br /> � Other: _Reti rees who are otherwise eligible per terms of Citv labor a�reement or <br /> 2. Full-Time Employee means: administrative policy. <br /> fr� A person who is regularly scheduled to work a minimum of 30 hours per week and who is actively at work <br /> and 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 /> � The limiting age for covered unmarried children is2.�_. <br /> ❑ The limiting age for covered unmarried children is ; age if a full-time sfudent. <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 /> ❑ The day of the month following the date of employment. <br /> � Other: <br /> GA-10-4 HCSC Rev.6/96 page 1 <br />