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Florida B4?e 0 d
<br />An Independent Licensee of the
<br />Blue Cross and Blue Shield Association
<br />Sales Representative:
<br />Broker:
<br />TPA:
<br />Provider Network(s):
<br />Utilization Review Vendor(s):
<br />Specific Deductible (per Covered Individual)
<br />Policy Year Maximum Specific Benefit
<br />Lifetime Maximum Specific Benefit
<br />Covered Benefits
<br />Specific Premium
<br />Composite Rate
<br />Total Lives
<br />Estimated Contract Specific Premium
<br />Contract Aggregating Specific Loss Fund
<br />Contract Basis
<br />Commission
<br />George Eppl
<br />$418,652
<br />Lockton Companies LLC
<br />Florida Blue
<br />60/12
<br />Florida Blue
<br />0.00%
<br />Florida Blue
<br />$1,172.74
<br />Lives
<br />Option
<br />$23,093,596
<br />$350,000
<br />$22,955,949
<br />Unlimited
<br />125%
<br />Unlimited
<br />125%
<br />Med, Rx Card
<br />1,641
<br />$24.31
<br />1,641
<br />$478,713
<br />$100,000
<br />60/12
<br />0.00%
<br />Covered Benefits
<br />Policy Year Maximum
<br />Aggregate Factors
<br />Composite Med & Rx Card Factor 1,641
<br />Estimated Contract Attachment Point 1,641
<br />Estimated Contract Minimum Attachment Point (100%)
<br />Aggregate Corridor
<br />Contract Basis
<br />Aggregate Premium
<br />STOP LOSS PROPOSAL FOR
<br />Indian River County Board of County Comm
<br />$300,000
<br />Unlimited
<br />Unlimited
<br />Med, Rx Card
<br />Effective Date: 10/01/2018
<br />Through Date: 09/30/2019
<br />$350,000
<br />Unlimited
<br />Unlimited
<br />Med, Rx Card
<br />$26.44 $21.26
<br />$520,656
<br />$418,652
<br />$2.0.0,000
<br />$200,000
<br />60/12
<br />60/12
<br />0.00%
<br />0.00%
<br />Med, Rx Card
<br />Med, Rx Card
<br />Med, Rx Card
<br />$1,000,000
<br />$1,000,000
<br />$1,000,000
<br />$1,172.74
<br />$1,165.75
<br />$1,172.74
<br />$23,093,596 i_
<br />$22,955,949
<br />$23,093,596
<br />$23,093,596
<br />$22,955,949
<br />$23,093,596
<br />125%
<br />125%
<br />125%
<br />60/12
<br />60/12
<br />60/12
<br />Composite Rate 1,641
<br />$1.68
<br />$1.63
<br />$1.68
<br />Estimated Contract Aggregate Premium 1,641
<br />$33,083
<br />$32,098
<br />$33,083
<br />Commission
<br />0.00%
<br />0.00%
<br />0.00%
<br />Total Combined Estimated Contract Premium
<br />$511,795
<br />$552,754
<br />$451,734
<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 (August 30. 2018) 10554202426-2018-546579-2-2 Page 3 of 6
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