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Section 2 How do you identify who is a special risk?, continued APPROVP0 T:) FORM AND LEGAL r -OR- B. List individuals falling into a special risk category directly on the reverse/second page of this form • • reviewing your employee attendance records, sick leave reports, and disability reports; and DYL/•ti*: FtCINGOLD�p�JNT�( ATT�RN�Y • consulting with your precertification, utilization review, and case management vendors. (Be sure to inc udd""e ransp ant can Idates.) Your medical management vendors may assist with the completion of this form. You may forward this form to any vendors Section 3 Identifying special risks Make sure you have read Name of plan sponsor Proposed effective date Today's date the directions on the Indian River Count Board of Count Comissioners 10/1/2014 9/16/2014 reverse/first page. Date of report Option A Attached reports must be within 30 days of proposed effective date Number of pages Attach the relevant ❑ Pending claims report reports and highlight(by ® Large claims report 50%of Specific deductible 8/20/2014 29 circling or using an ❑ Precertification report asterisk or other mark) ❑ Subrogated claims report special risk individuals. ® Other report(please describe) High Cost Claim Summary 8/20/2014 1 &Detail Report Option B List special risk Category- individuals directly Name or ID number E= Employee Total dollar on this form. of individual who is/may be C = COBRA amount of claims a special risk D = Dependent Sex paid within past IMPORTANT! attach addt'I pages if needed R= Retiree Date of birth M/F Diagnosis/medical condition Date of onset 12 months Individuals must either $ be:(A)highlighted on $ an attached report or $ (B)listed on this form. $ Section 4 Acknowledgment and signature Return this completed m form your broker We will use the information you provide on this form to underwrite the stop-loss insurance you have applied for and to determine the appropriate or Sun Life Financial coverage,deductibles,and premium rates for that insurance. If you fail to disclose any person as a special risk who should have been disclosed as a presentative within special risk and submit a claim relating to that person,we may decline or limit coverage with respect to that person,retroactive to the original re re days to the proposed effective date of your stop-loss policy with us. Your signature on this form represents to us that: policy effective date. I. You or your authorized representative provided the requested reports with special risk individuals identified; and 2. You or your authorized representative consulted with your precertification, utilization review, and case management vendors and with your third party administrator or former third party administrator to obtain the information required to complete this form; and 3. You or your authorized representative provided information about any individual who is eligible under your employee benefit plan as of the date you signed this form who is, or may be,a special risk. Sign re of authorized r resenPtive of plan sponsor Name(please print) Title(please print) Date signed �sr Joseph A. Baird County Administrator 09/29/14 XGR/1254 Stop-Loss special risk que nnaire Page 2 of 2 10/10