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Fl,rrP4& B& (e 0 d <br />An Independent Licensee of the STOP LOSS PROPOSAL FOR <br />Blue Cross and Blue Shield Association Indian River County Board of County Comm <br />Sales Representative: <br />Broker: <br />TPA: <br />Provider Network(s): <br />Utilization ReviewVendor(s): <br />LOCKTON COMPANIES LLC <br />Florida Blue <br />Florida Blue <br />Florida Blue <br />Specific: (Check one) Lives <br />Option 2 <br />Option <br />Specific Deductible (per Covered Individual) <br />$400,000 <br />$425,000- <br />425,000Policy <br />PolicyYear Maximum Specific Benefit <br />Unlimited <br />Unlimited <br />Lifetime Maximum Specific Benefit <br />Unlimited <br />Unlimited <br />Covered Benefits <br />Med, Rx Card <br />Med, Rx Card <br />Specific Premium <br />125% <br />72/12 <br />125% <br />72/12 <br />Composite Rate 1,666 <br />$25.61 <br />$22.99 <br />Total Lives 1,666 <br />$1.92 <br />$38,385 <br />0.00% <br />$1.94 <br />$38,784 <br />0.00% <br />Estimated Contract Specific Premium <br />I $511,995 <br />$459,616 <br />Contract Aggregating Specific Loss Fund <br />$100,000 <br />$100,000 <br />Contract Basis <br />j 72/12 <br />72/12 1 <br />Commission <br />I 0.00% <br />0.00% <br />Covered Benefits <br />Policy Year Maximum <br />Med, Rx Card <br />$1,000,000 <br />Med, Rx Card <br />$1,000,000 <br />Aggregate Factors <br />Composite Med & Rx Card Factor. 1,666 <br />$1,348.15 <br />$1,350.82 <br />Estimated Contract Attachment Point 1,666 <br />$26,952,215 <br />$27,005,593 <br />Estimated Contract Minimum Attachment Point (100%) <br />$26,952,215 <br />$27,005,593 f <br />Aggregate Corridor <br />Contract Basis <br />125% <br />72/12 <br />125% <br />72/12 <br />Aggregate Premium <br />! <br />Composite Rate . 1,666 <br />Estimated Contract Aggregate Premium 1,666 <br />Commission <br />$1.92 <br />$38,385 <br />0.00% <br />$1.94 <br />$38,784 <br />0.00% <br />Total Combined Estimated Contract Premium <br />$550,380 <br />$498,401 <br />Effective Date: 10/01/2019 <br />Through Date: 09/30/2020 <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) 10580251945-2019-563895-4-3 14age 3 of 6 <br />