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q ' IU' I � 1I`t i <br /> STOP LOSS PROPOSAL FOR 8 . <br /> Indian River County Board of County Comm �� /a _ �� � L ' FE ' " sup ;, " cE <br /> 001.1I'ANY <br /> PROPOSAL NOTES <br /> • The rates in this proposal are firm . Please provide a signed proposal , binder check and signed application . <br /> • The specific rates in this proposal are based on an aggregating specific arrangement. Total Specific Liability includes estimated <br /> contract specific <br /> premium and the aggregating specific fund . <br /> • Human Organ Transplant benefits are payable in accordance with the underlying plan and are subject to the proposed Lifetime Maximum <br />Specific <br /> Benefit offered within this proposal . <br /> PROPOSAL ACCEPTANCE <br /> Please acknowledge acceptance of the terms in this proposal by signing and returning within 30 days (no signed proposal will be <br />accepted after the <br /> effective date) . Please also indicate which option is chosen and whether Aggregate is to be included , by checking the appropriate <br /> boxes on the <br /> previous page . Failure to remit the signed agreement within the same period will result in updated large claim disclosure (and <br />claims) being required <br /> for our review. <br /> SignatureTitle : /)�Yii44 �> 1)j'19 lc; r <br /> - <br /> Accept /onthe day of 1` '20 4 <br /> Stop Loss coverage is underwritten by HM Life Insurance Company . Pittsburgh . PA , under policy form HL 601 (905 <br />) or similar, in <br /> certain states the requested coverage may not be available . As included herein , " HMIG " refers to the Stop Loss carrier <br />. <br /> Underwriter. REB (August 16 . 2012 ) 1011 52722-2012 -225125 -2-2 Page 2 of <br />