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� ADMIfVISTRATIVE SERVICES � <br /> BENEFIT PROGRAM APPLICATION <br /> Employer Group No.(s) 992844 Section No.(s) O 100 & 0200 <br /> Empioyer Group Name: Ci ty of Decatur <br /> (Specity ihe empbyer,applying for coverage.Names of subsidiary and aftiliated companies must also be inGuded. <br /> AN EMPLOYEE BENEFIT PLAN MAY NOT BE NAMED.) <br /> Address: #1 Civic Center Plaza, Decatur, IL 62523 __ _ <br /> Administrative Contact: Gerard Bauer Effective Date of Coverage: 11/Ol/89 <br /> 1. Eligible Person means: <br /> � A full-time employee of the Employer <br /> ❑ A fU��-t11T12 BfTlp�O)/88 WflO IS a fTl@fT1f�8f Of(nameotunianaassociation) <br /> � Retirees <br /> 2. Classifications of Eligible Persons: <br /> � All persons who meet the definition of Eligible Person stated above. <br /> ❑ Class A: All persons who meet the definition of Eligible Person stated above including persons who are <br /> affected by.TEFRA and/or COBRA and who have not selected Medicare as their primary coverage. <br /> Class B: All persons who meet the definition of Eligible Person stated above who are not affected by <br /> TEFRA and/or COBRA and are eligible for and have their primary coverage provided by Medicare. <br /> 0 See attached Classifications. <br /> 3. Full-Time Employee means: <br /> � A person who is regularly scheduled to work a minimum of.�_hours per week and who is aCtively <br /> at work and on the permanent payroll of the Employer. <br /> ❑ <br /> 4. Persons not Eligible are: <br /> A person who does not meet the definition of Eligible Person stated above or a person who does meet <br /> the definition of Eligible Person stated above but is affected by TEFRA and/or COBRA and has selected <br /> Medicare as his Primary Coverage. � <br /> In the event a spouse of an Eligible Person,who is otherwise eligible for coverage as a Covered Person <br /> and who is affected by TEFRA and/or COBRA, selects Medicare as his/her primary coverage,then, such <br /> spouse shall not be eligible for coverage. . � <br /> 5. The Effective Date of Termination for a person who ceases to meet the definition of an Eligible Person: <br /> ❑ The date such person ceases to meet the definition of Eligible Person. <br /> x] The last day of the calendar month in which such person ceases to meet the definition of an Eligible <br /> Person. . <br /> ❑ <br /> 6. ❑ The limiting age for covered unmarried children is 23;coverage is autamatically terminated on the <br /> birthdate. � <br /> �Cj The last day of the calendar mon�h in which the limitinq aqe is reached. I <br /> 7. The Eligibility Date for a person who becomes an Eligible Person after the Effective Date of the Employer's <br /> Health Care Plan: ' <br /> �l The date of employment <br /> ❑ The first day of the month following full calendar month(s)of employmeni. <br /> 0 The first day of the month following the date of employment. <br /> ❑ The day of employment. <br /> ❑ <br /> C�A-�r?.:�., � P2ge ] o!4 <br />