Laserfiche WebLink
Flortd,a Blue 0 d <br />An Independent Licensee of the <br />Blue Cross and Blue Shield Association <br />Sales Representative: George Eppl <br />Broker: Gehring Group Inc <br />TPA: Florida Blue <br />Provider Network(s): Florida Blue <br />Utilization Review Vendor(s): Florida Blue <br />�ecific- (Check r <br />STOP LOSS PROPOSAL FOR <br />Indian River County Board of County Comm <br />Specific Deductible (per Covered Individual) <br />$300,000 ' <br />$300,000 <br />Policy Year Maximum Specific Benefit <br />Inforce <br />Unlimited <br />Lifetime Maximum Specific Benefit <br />Inforce <br />Unlimited <br />Covered Benefits <br />Med, Rx Card <br />Med, Rx Card <br />Specific Premium <br />$21,051,927 <br />$21,055,039 <br />Composite Rate 1,621 <br />$24.00 <br />$23.87 <br />Total Lives 1,621 <br />- ---------------------- <br />125% <br />125% <br />Estimated Contract Specific Premium <br />$466,848 <br />$464,319 <br />Contract Aggregating Specific Loss Fund <br />$148,750 <br />$148,750 <br />Contract Basis <br />36/12 <br />48/12 <br />Commission <br />10.00% ' <br />0.00% <br />Covered Benefits <br />Med, Rx Card <br />Med, Rx Card <br />Policy Year Maximum <br />$1,000,000 <br />$1,000,000 <br />Aggregate Factors <br />Composite Med & Rx Card Factor 1,621 <br />$1,082.25. <br />$1,082.41 <br />Estimated Contract Attachment Point 1,621 <br />$21,051,927 <br />$21,055,039 <br />Estimated Contract Minimum Attachment Point (100%) <br />$21,051,927 <br />$21,055,039 <br />Aggregate Corridor <br />125% <br />125% <br />Contract Basis <br />36/12 <br />48/12 <br />Aggregate Premium_ <br />_ <br />Composite Rate 1,621 <br />$1.56 <br />$1.47 <br />Estimated Contract Aggregate Premium 1,621 <br />$30,345 <br />$28,594 <br />Commission <br />10.00% <br />0.00% <br />Total Combined Estimated Contract Premium <br />$497,193 <br />$492,914 <br />Effective Date: 10/01/2017 <br />Through Date: 09/30/2018 <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 (September 1, 2017) 10533093820-2017-531476-3-4 Page 1 of 4 <br />