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Floraa &ea
<br />An Independent Licensee of the
<br />Blue Cross and Blue Shield Association
<br />STOP LOSS PROPOSAL FOR
<br />Indian River County Board of County Comm
<br />Sales Representative:
<br />Broker:
<br />TPA:
<br />Provider Network(s):
<br />Utilization Review Vendor(s):
<br />George Eppl
<br />LOCKTON COMPANIES LLC
<br />Florida Blue
<br />Florida Blue
<br />Florida Blue
<br />Effective Date: 10/01/2019
<br />Through Date: 09/30/2020
<br />Specific: (Check one) Lives
<br />Current V Renewal
<br />t• Option 1
<br />Specific Deductible (per Covered Individual)
<br />Policy Year Maximum Specific Benefit
<br />Lifetime Maximum Specific Benefit
<br />Covered Benefits
<br />Specific Premium
<br />$300,000
<br />Inforce
<br />Inforce
<br />Med, Rx Card
<br />$300,000
<br />Unlimited
<br />Unlimited
<br />Med, Rx Card
<br />$350,000
<br />Unlimited
<br />Unlimited
<br />Med, Rx Card
<br />Composite Rate
<br />Total Lives
<br />Estimated Contract Specific Premium
<br />Contract Aggregating Specific Loss Fund
<br />Contract Basis
<br />Commission
<br />1,666
<br />1,666
<br />$30.14
<br />$38.88
<br />$31.35
<br />$602,559
<br />$100,000
<br />60/12
<br />' 0.00%
<br />$777,289
<br />$100,000
<br />72/12
<br />0.00%
<br />$626,749
<br />$100,000
<br />72/12
<br />0.00%
<br />Aggregate: (Include? • Yes • No)
<br />Covered Benefits
<br />Policy Year Maximum
<br />Aggregate Factors
<br />Med, Rx Card
<br />$1,000,000
<br />Med, Rx Card
<br />$1,000,000
<br />Med, Rx Card
<br />$1,000,000
<br />Composite Med & Rx Card Factor 1,666
<br />Estimated Contract Attachment Point 1,666
<br />Estimated Contract Minimum Attachment Point (100%)
<br />Aggregate Corridor
<br />Contract Basis
<br />Aggregate Premium
<br />$1,165.75
<br />$23,305,674
<br />$23,305,674
<br />125%
<br />60/12
<br />$1,334.80
<br />$26,685,322
<br />$26,685,322
<br />125%
<br />72/12
<br />$1,342.81
<br />$26,845,458
<br />$26,845,458
<br />125%
<br />72/12
<br />Composite Rate 1,666
<br />Estimated Contract Aggregate Premium 1,666
<br />Commission
<br />Total Combined Estimated Contract Premium
<br />$1.63 $1.82
<br />$32,587 $36,385
<br />0.00% 0.00%
<br />$635,146 $813,674
<br />$1.87
<br />$37,385 '
<br />0.00% ti
<br />$664,134
<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: KMC (July 25, 2019)
<br />10580251945-2019-563895-4-3 Page 1 of 6
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