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<br /> Flo%W4&B440 d
<br /> An Independent Licensee of the STOP LOSS PROPOSAL FOR
<br /> Blue Cross and Blue Shield Association Indian River County Board of County Comm
<br /> Sales Representative: George Eppl Effective Date: 10/01/2016
<br /> Broker: Gehring Group Inc Through Date: 09/30/2017
<br /> TPA: Florida Blue
<br /> Provider Network(s): Florida Blue
<br /> Utilization Review Vendor(s): Florida Blue
<br /> Specific: (Check one) Lives Current 0 Renewal 0 Option I Option
<br /> Specific Deductible(per Covered Individual) i $300,000 $300,000 $325,000 $350,000
<br /> Policy Year Maximum Specific Benefit j Inforce Unlimited Unlimited Unlimited
<br /> Lifetime Maximum Specific Benefit Inforce Unlimited Unlimited Unlimited
<br /> Covered Benefits Med,Rx Card Med,Rx Card , Med,Rx Card Med,Rx Card
<br /> Specific Premium
<br /> Composite Rate 1,635 $22.02 + $24.00 $21.67 $20.02
<br /> Total Lives 1,635
<br /> Estimated Contract Specific Premium $432,032 $470,880 $425,165 $392,792
<br /> Contract Aggregating Specific Loss Fund ! $148,750 $148,750 $148,750 $148,750
<br /> Contract Basis 24/12 -36/12 36/12 f 36/12
<br /> Commission 10.00% 10.00% 10.00% f 10.00%
<br /> Aggregate: (Include? 0 Yes No)
<br /> Covered Benefits Med,Rx Card Med,Rx Card Med,Rx Card Med,Rx Card
<br /> Policy Year Maximum $1,000,000 $1,000,000 $1,000,000 ( $19000,000
<br /> I Aggregate Factors
<br /> Composite Med&Rx Card Factor 1,635 $1,010.54 $1,082.25 $1,085.50 $1,088.75
<br /> Estimated Contract Attachment Point 1,635 $19,826,795 $21,233,745 $21,297,510 $21,361,275
<br /> Contract Minimum Attachment Point(100%) $19,826,795 $21,233,745 $21,297,510 $21,361,275
<br /> Aggregate Corridor 125% I 125% 125% I 125%
<br /> Contract Basis 24/12 36/12 36/12 36/.12
<br /> { Aggregate Premium
<br /> Composite Rate 1,635 ! $1.47 $1.56 $1.59 $1.61
<br /> Estimated Contract Aggregate Premium 1,635 $28,841 $30,607 $31,196 $31,588
<br /> Commission 1000% 10.00% 10.00% 10 00%
<br /> Total Combined Estimated Contract Premium $460,874 $501,487 $456,361 $4249380
<br /> Note:This proposal is not complete unless accompanied by the proposal notes and the basis of offer noted on the following pages.
<br /> Individual Special Requirements:
<br /> Underwriter REB(August 8,2016) 10500541335-2016-503868-6-4 Page 1 of 4
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