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� <br /> .� ,� ' . <br /> `' � � � <br /> 4 . 04 Filing a Claim. An Employee may submit a claim for <br /> benefits under the Plan by filing the claim at: <br /> Fort Dearborn Life Insurance Company <br /> 233 North Michigan Avenue <br /> Chicago, Illinois 60601 <br /> 4 . 05 Claims Procedure. <br /> (a) Claims for Benefits. The Plan Administrator <br /> shall, within 90 days of receipt of a properly filed claim, <br /> review the claim and notify the Participant, former <br /> employee, or employee in writing, of his eligibility or <br /> noneligibility for benefits. In the event of the legal <br /> disability or death of a Participant, employee or former <br /> employee, his legal representative or the representative of <br /> his estate may initiate any claim which otherwise could have <br /> been initiated by the Participant, employee or former <br /> employee. <br /> In the event any claim is denied, in whole or in part, <br /> or if any individual claiming eligibility is denied <br /> eligibility hereunder, a written notice shall be issued by <br /> the Plan Administrator (within a reasonable time after <br /> receipt of the claim) setting forth the following: <br /> (i) the specific reason or reasons for <br /> eligibility or benefits; <br /> (ii) a specific reference to the pertinent Plan <br /> provisions upon which the denial is based; <br /> (iii) a description of any additional material or <br /> information necessary for the claimant to perfect a <br /> claim and an explanation why such material or <br /> information is necessary; and <br /> (iv) an explanation of the Plan's Claim Review <br /> Procedure. <br /> (b) Right to Review. Any employee or former employee <br /> otherwise eligible or claiming participation hereunder, <br /> Participant or beneficiary or a deceased Participant <br /> , ("claimant") , shall be entitled to appeal the denial of his <br /> claim by submitting a properly completed form to the Plan <br /> Administrator and the Employer along with a written <br /> statement of claimant's contentions and any supporting <br /> documents, no later than sixty (60) days after receipt of <br /> the denial notice described in Paragraph 4 . 05 (a) above. <br /> Appeals shall be filed at: City of Decatur <br /> #1 Civic Center Plaza <br /> Decatur, IL 62523 <br /> Attn: Risk Management <br /> FSA-21-192 <br /> -5- <br />