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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: 10/01/2021
<br />Through Date: 09/30/2022
<br />Specific:
<br />Med, Rx Card
<br />Med, Rx Card
<br />Option 1
<br />N Option
<br />Specific Deductible (per Covered Participant)
<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 />_
<br />$40,681
<br />--
<br />__ _ _
<br />Composite Rate 1,670
<br />$53.66
<br />$62.51
<br />$55.14
<br />$50.60
<br />Total Lives 1,670
<br />$1,116,028
<br />$1,293,382
<br />_
<br />$1,055,707
<br />Estimated Contract Specific Premium
<br />$1,075,346
<br />$1,252,700
<br />$1,105,006
<br />$1,014,024
<br />Contract Aggregating Specific Loss Fund
<br />$100,000
<br />$100,000
<br />$100,000
<br />$100,000
<br />Contract Basis
<br />84/12
<br />96/12
<br />96/12
<br />96/12
<br />Commission
<br />0.00%
<br />0.00%
<br />0.00%
<br />0.00%
<br />Covered Benefits
<br />Med, Rx Card
<br />Med, Rx Card
<br />Med, Rx Card
<br />Med, Rx Card
<br />Policy Year Maximum
<br />$1,000,000
<br />$1,000,000
<br />$1,000,000
<br />$1,000,000
<br />Factors__
<br />84/12
<br />96/12
<br />96/12
<br />96/12
<br />_Aggregate
<br />Composite Med, Rx Card Factor
<br />1,670 $1,49_4.23
<br />$1,494.23
<br />$1,498.71
<br />$1,503.20
<br />Estimated Contract Attachment Point
<br />1,670 $29,944,369
<br />$29,944,369
<br />$30,034,148
<br />$30,124,128
<br />Estimated Contract Minimum Attachment Point (100%)
<br />$29,944,369
<br />$29,944,369
<br />$30,034,148
<br />$30,124,128
<br />Aggregate Corridor
<br />125%
<br />125%
<br />125%
<br />125%
<br />Contract Basis
<br />84/12
<br />96/12
<br />96/12
<br />96/12
<br />Aggregate Premium
<br />Composite Rate 1,670
<br />$2.03
<br />$2.03
<br />$2.05
<br />$2.08
<br />Estimated Contract Aggregate Premium 1,670
<br />$40,681
<br />$40,681
<br />$41,082
<br />$41,683
<br />Commission
<br />0.00%
<br />0.00%
<br />0.00%
<br />_ 0.00%
<br />Total Combined Estimated Contract Premium
<br />$1,116,028
<br />$1,293,382
<br />$1,146,088
<br />$1,055,707
<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 (August 2, 2021) 10816062764-2021-609536-4-4 Page 1 of 6
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