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i An Independent Licensee of the STOP LOSS PROPOSAL FOR Blue Cross and Blue Shield Association Indian River County Board of County Comm • The rates and factors in this proposal are based on the disclosure of all individuals considered a special enrollee due to having previously satisfied the plan's lifetime maximum. Written acceptance by HM must be acknowledged before terms of coverage for such individuals are included under HM's stop loss policy. • Any stop loss policy issued by us may be rescinded or re-underwritten if any information requested in connection with this proposal was intentionally concealed or misrepresented by or on behalf of the Applicant and/or the Applicant's Agent,or if the Applicant and/or the Applicant's Agent commits fraud. • As used above: An"Agent"is the Applicant's representative,including but not limited to,the agent,producer or broker of record,or Claims Administrator The"Applicant"is the entity,or that entity's authorized representative,that has contracted with us to provide stop loss coverage. A "Claims Administrator"is a third party administrator(TPA)designated by the Applicant and approved by us. "Claim Information"consists of Complete Details of the data requested by us in connection with this proposal following a Diligent Review;such information includes but is not limited to Know or potential catastrophic claims,large claims and/or shock losses. "Complete Details"includes the name,social security number (or unique identifier),date of birth,diagnosis,prognosis(unless prognosis cannot be obtained due to reasons beyond your or your Claims Administrator's control)of the plan's participants and the name of the provider providing treatment to any such participant covered by or eligible for coverage. A"Diligent Review"consists of a complete review by you,and/or your Claims Administrator and/or your Agent prior to the date Known or potential catastrophic claims,large claims and/or shock losses are requested by us in connection with this proposal. "Disclosure"consists of Complete Details and any other documentation requested by us in connection with this proposal following a Diligent Review including but not limited to census information and Claim Information. We consider information in connection with this proposal"Known"if,prior to the date or dates we request such information(including but not limited to Disclosure and Claim Information)a reasonable person can assume that you, and/or your Claims Administrator and/or your Agent had knowledge of any information that affects or may affect the administration or underwriting of any coverage issued following acceptance of coverage by us. Coverage is underwritten by Florida Blue,Jacksonville, FL and is administered by HM Life Insurance Company,Pittsburgh, PA. HM Life Insurance Company is an independent company providing only administrative services. Underwriter REB(August 8,2016) 10500541335-2016-503868-6-4 Page 4 of 4