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EXHIBIT A <br />CLIENT APPLICATION <br />October 1, 2019 <br />[IMPORTANT — PLEASE READ CAREFULLY: Client should complete Section A and carefully review this <br />Exhibit A. which has been completed by Administrator, in order to ensure the accuracy and completeness of <br />such information. Client shall promptly notify Administrator of any inaccuracy or omission with respect to <br />such terms and conditions, if applicable (including, without limitation, the Client Information in Section A).] <br />A. INFORMATION ABOUT CLIENT <br />Client Name: <br />Indian River County Board of County Commissioners <br />HR/Primary Contact: <br />Phone <br />Mail Address: <br />1801 27t' Street <br />HR Contact Email: <br />Fax: <br />City/State/Zip: <br />Vero Beach, FL 32960 <br />Billing Contact: <br />Phone: <br />Main Phone: <br />Billing Contact Email: <br />Fax: <br />Send Invoices and Confidential Standard Reports to: <br />Authorized Website Users of Client (User's Name and E-mail Address): <br />* Note: Client may add or delete Authorized Website Users by providing written notice of such changes to <br />Administrator pursuant to the notice provisions of Article VIII.B of the Agreement. <br />B. PLAN DESIGN; MEMBER COST SHARE <br />Member Cost Share: <br />Please see current Summary of Benefits. <br />Client represents and warrants that the design of Client's Plan as reflected in a Plan design document for Client <br />("PDD"), accurately reflects the applicable terms of Client's Plan for purposes of this Agreement. Client shall provide <br />Administrator with ninety (90) days prior written notice of any proposed changes to the design of Client's Plan <br />(including the PDD), which changes shall be consistent with the scope and nature of the services to be provided by <br />Administrator under this Agreement. Client agrees that it is responsible for Losses resulting from any failure to <br />implement Plan design changes which are not communicated in writing to Administrator. In addition, Client shall <br />notify Members of any Plan design changes prior to the effective date of any such changes. <br />NOT FOR DISTRIBUTION. THE INFORMATION CONTAINED HEREIN IS CONFIDENTIAL, PROPRIETARY <br />AND CONSTITUTES TRADE SECRETS OF ESI AND RXBENEFITS <br />2 <br />