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At;independent Liccr+see 01 thu <br /> 8111"-CSTOP LOSS PROPOSAL FORC-55 and Bine Shield A,s�ciaf cr. <br /> Indian River County BOCC <br /> PROPOSAL NOTES <br /> ;j <br /> i <br /> The rates and factors in this proposal are firm. Please provide a signed proposal,binder check and signed application. <br /> Large claim data must be submitted for any claims that are at or have the likelihood to exceed 50%of the group specific deductible.Large claim <br /> data must include:age,sex,diagnosis,prognosis,treatment plan,case management notes(if applicable),Pre-Cert and paid/pended claims. <br /> • The specific rates in this proposal are based on an aggregating specific arrangement. Total S <br /> premium and the aggregating specific fund. peck Liability incudes estimated contractspecific <br /> • Human Organ Transplant benefits are payable in accordance with the underlying plan and are subject to the proposed Lifetime Maximum Specific <br /> Benefit offered within this proposal. <br /> PROPOSAL ACCEPTANCE <br /> Please acknowledge acceptance of the terms in this proposal by signing and returning by 08/28/2015(no signed proposal will be accepted after the <br /> effective date). Please also indicate which option is chosen and whether Aggregate is to be included,by checking the appropriate boxes on the <br /> previous page. Failure to remit the signed agreement within the same period will result in updated large claim disclosure(and Gaims)being required <br /> for our review. <br /> Signature: Title: <br /> Accepted on the day of 20 <br /> APPROVED AS TO FORM <br /> AND LEGAL SUFFICI <br /> I <br /> BY <br /> i <br /> DYLAN REINGOLD <br /> COUNTY ATTORNEY <br /> r <br /> i <br /> ,�.fi;"• � .: r1J: f` •�i <br /> - ;�r.e`;r�::;r,,i`:1 ..' `.` , '(iii?� ..•4 <br /> 57 <br />