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STOP LOSS PROPOSAL FOR WIL mo , <br /> ` <br /> LIFE INSURANCE <br /> Indian River County Board of County Comm COMPANY <br /> Sales Representative : Ronald Brodeur Effective Date : 10/01 /2012 <br /> Broker: Gehring Group Inc Through Date : 09/30/2013 <br /> TPA : Blue Cross Blue Shield of Florida <br /> Provider Network(s) : Blue Cross Blue Shield of Florida <br /> Utilization Review Vendor(s) : Blue Cross Blue Shield of Florida <br /> Specifics (Check one) Lives pl, Option 1 . N Option 2 M Option <br /> Specific Deductible (per Covered Individual) $ 250 , 000 $275 , 000 $ 300 , 000 <br /> Policy Year Maximum Specific Benefit Unlimited Unlimited Unlimited <br /> Lifetime Maximum Specific Benefit Unlimited Unlimited Unlimited <br /> Covered Benefits Med , Rx Card Med , Rx Card Med , Rx Card <br /> Specific Premium <br /> Composite Rate 11565 $ 17 .45 $ 15 . 17 $ 13 . 50 <br /> Total Lives 11565 <br /> Estimated Contract Specific Premium $ 327 , 711 $284 , 893 $ 253 , 530 <br /> Contract Aggregating Specific Loss Fund $ 148 ,750 $ 148 , 750 $ 148 , 750 <br /> Contract Basis 24/12 24112 24/ 12 <br /> Commission 9 . 80 % 9 . 80 % 9 . 80 % <br /> Aggregates (include? 4 Yes 0 No) <br /> Covered Benefits Med , Rx Card Med , Rx Card Med , Rx Card <br /> Policy Year Maximum $ 1 , 000 , 000 $ 1 , 000 , 000 $ 1 , 000 , 000 <br /> Aggregate Factors <br /> Composite Proposed Factor 11565 $ 815 . 36 $ 819 .44 $ 822 . 70 <br /> Estimated Contract Attachment Point 11565 $ 15 , 312, 461 $ 15 , 389 , 083 $ 15 ,450 , 306 <br /> Contract Minimum Attachment Point ( 100 %) $ 151312 , 461 $ 15 , 389 , 083 $ 15 , 450 , 306 <br /> Aggregate Corridor 125 % 125 % 125 % <br /> Contract Basis 24112 24/12 24/ 12 <br /> Aggregate Premium <br /> Composite Rate 11565 $ 1 . 97 $ 2 . 01 $ 2. 06 <br /> Estimated Contract Aggregate Premium 11565 $ 36 , 997 $ 37 ,748 $ 38 , 687 <br /> Commission 11 . 20 % 11 . 20 % 11 . 20 % <br /> Total Combined Estimated Contract Premium $364,708 $322 , 640 $292 , 217 <br /> Note : This proposal is not complete unless accompanied by the proposal notes and the basis of offer noted on the following pages <br />. <br /> Individual Special Requirements : <br /> Underwriter REB ( August 16 . 2012) 10176052722 -2012 -225125 - 2-2 Fagg 1 at 3 <br />