Laserfiche WebLink
An Independent Licensee of the STOP LOSS PROPOSAL FOR <br /> Blue Cross and Blue Shield Association Indian River County Board of County Comm <br /> PROPOSAL NOTES <br /> • The rates and factors in this proposal are firm. Please provide a signed proposal. <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 speck rates in this proposal are based on an aggregating specific arrangement. Total Specific Liability includes estimated 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 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 08/29/2016(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 claims)being required <br /> for our review All payments after the effective date of this policy,found on the previous page,must use the rates selected. Any deviation from the <br /> rates specified could result in an underpayment leading to a possible policy cancellation. <br /> BOARD OF COUIVPY COMMIISSIIONERS <br /> OF INDIAN <br /> �CO`t�J�-C <br /> Signature: CLaw.NZY Title: Chairman <br /> Bob Solari <br /> Accepted on the 16th day of August ,20 16 •.•'tai G� SS'' <br /> • �a, • •• io' . <br /> ATTEST: <br /> Jeffrey R. Smith, Clerk of Court and Ccmptroller i*' • ',a <br /> BY: <br /> De uty Clerk :9y, f •Q��• <br /> •.9�`FR COUNTo•• <br /> Underwriter-REB(August 8,2016) 10500541335-2016-503868-6-4 Page 2 of 4 <br />