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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 />George Eppl
<br />LOCKTON COMPANIES LLC
<br />Florida Blue
<br />Florida Blue
<br />Florida Blue
<br />STOP LOSS PROPOSAL FOR
<br />Indian River County Board of County Comm
<br />Effective Date: 10/01/2020
<br />Through Date: 09/30/2021
<br />Specific: (Check one) Lives
<br />Current Qj
<br />Renewal
<br />0 Option 1
<br />Option
<br />Specific Deductible (per Covered Individual)
<br />$300,000
<br />$300,000
<br />$325,000
<br />$350,000
<br />Policy Year Maximum Specific Benefit
<br />Inforce
<br />Unlimited
<br />Unlimited
<br />Unlimited
<br />Lifetime Maximum Specific Benefit
<br />Inforce
<br />Unlimited
<br />Unlimited
<br />Unlimited
<br />Covered Benefits
<br />Med, Rx Card
<br />Med, Rx Card
<br />Med, Rx Card
<br />Med, Rx Card
<br />Specific Premium
<br />Composite Rate 1,688 $38.88 $53.66 $47.95 $44.53
<br />Total Lives 1,688 _
<br />Estimated Contract Specific Premium $787,553 $1,086,937 $971,275 $902,000
<br />Contract Aggregating Specific Loss Fund $100,000 $100,000 $100,000 $100,000
<br />Contract Basis
<br />Commission
<br />72/12
<br />0.00%
<br />84/12
<br />0.00%
<br />84/12
<br />0.00%
<br />84/12
<br />0.00%
<br />-
<br />Aggregate: ..
<br />Covered Benefits
<br />Policy Year Maximum
<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 />Med, Rx Card
<br />$1,000,000
<br />Aggregate Factors
<br />Composite Med, Rx Card Factor 1,688
<br />$1,334.80
<br />$1,494.23
<br />$1,498.71
<br />$1,503.20
<br />Estimated Contract Attachment Point 1,688
<br />$27,037,709
<br />$30,267,123
<br />$30,357,870
<br />$30,448,819
<br />Estimated Contract Minimum Attachment Point (100%)
<br />$27,037,709
<br />$30,267,123
<br />$30,357,870
<br />_$30,448,819
<br />Aggregate Corridor
<br />Contract Basis
<br />125%
<br />72/12
<br />125%
<br />84/12
<br />125%
<br />84/12
<br />125%
<br />84/12
<br />Aggregate Premium
<br />Composite Rate 1,688 $1.82 $2.03
<br />Estimated Contract Aggregate Premium 1,688 $36,866 $41,120
<br />Commission 0.00% 0.00%
<br />Total Combined Estimated Contract Premium $824,419 $1,128,057
<br />$2.06
<br />$2.08
<br />$41,727
<br />$42,132
<br />0.00%
<br />0.00%
<br />$1,013,003 $944,132
<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 27, 2020)
<br />i
<br />10683960576-2020-588385-3-3
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