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'6 For employers who are providers of medical services only ( i e hospitals, clinics, etc ) The Related Provider Reimbursement Percentage applied to Eligible Claims Expenses for Related Provider Services will be n/a %for the Specific Benefit and n/a%for the Aggregate Benefit. '7 Retiree information 1. Specific Benefit: Is retiree coverage included? ❑ No ® Yes 2. Aggregate Benefit: Is retiree coverage included? ❑ No ® Yes '8 Additional benefits (Must Be Underwriting Approved) These are programs and SunExcel®Transplant Program Clinical Trials Benefit Provision enhancements to your Stop-Loss coverage. ® Elect E]Decline EJ Elect ® Decline No New Special Conditions Rider at Renewal ® Elect ❑ Decline '9 Certification and Signature Please return this form This application does not bind coverage. The applicant agrees to provide Sun Life Assurance and all additional Company of Canada with a current census of all eligible individuals, disclosure of all special risks on required documentation the Special Risk Questionnaire and a complete Plan document no later than the effective date to your Sun Life specified in section 1. Upon approval of this application, Sun Life Assurance Company of Canada Financial Group Office. will issue a Stop-Loss insurance policy with insurance coverage to become effective on the effective date. This application will be attached to and made a part of the Stop-Loss policy. The policy will be void if the applicant has concealed or misrepresented any material fact or circumstance concerning the subject of this application. Please read the fraud warning below before signing this application. State law requires that we notify you of the following: [(If the applicant organization is headquartered in Colorado, District of Columbia, Florida, Kansas, Kentucky, Maryland, New Jersey, Oregon, Rhode Island, Tennessee, Vermont, Virginia, and Washington,please see Page 4)] Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. Name of authorized representative of plan sponsor Title Joseph A. Baird County Administrator — i Signature of authorized re"sentat've Today's date X �' 09/29/2014 Sign re7frroker X Ct Print na a of ag nt/154 ---- Kurt N. Gehring Florida agent/broker license ID number Amount paid with A094973 this application Countersigned by licensed resident agent(when required by law) $0.00 X APPROVED AS AND LEGAL SUFFICIENCY BY DYLAN REINGOLD COUNTY ATTORNEY XGR/2989 • Stop-Loss Application Page 3 of 4