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ADDITIONAL PROVISIONS: ' - � <br /> On plan P06856, a $25 per visit maximum on outpatient mental illness and <br /> outpatient substance abuse treatment. � <br /> David Underkoffler � <br /> Sale�4apresentative �217)698-51�� Signature of Authorized Purchaser <br /> t� <br /> City Manager <br /> District Phone No. Title <br /> Larrv Steilin4 10/22/96 <br /> Producer Representative � � � <br /> Behnke & Company <br /> � �___. <br /> Producer Firm Witness <br /> 225 S Main St. Decatur, IL 62525 <br /> Producer Address $ Amount Submitted <br /> 37-1139471 <br /> Ta�c I.D.No. <br /> BENEFIT BOOKLET INFORMATION <br /> UNDERWRITING USE ONLY Number of Benefit Bookle4s: �� <br /> Date BPA approved: <br /> � Include FDL benefits <br /> Signature of Undervvriter: Mail booklets to: <br /> � GROUP � DISTR�CT <br /> GA-10-4 HCSC Rev.6/96 page 4 <br />