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Fl - & Blue d An Independent Licensee of the Blue Cross and Blue Shield Association PROPOSAL NOTES • The rates and factors in this proposal are firm. Please provide a signed proposal. STOP LOSS PROPOSAL FOR Indian River County Board of County Comm • Large claim data must be submitted for any claims that are at or have the likelihood to exceed 50% of the group specific deductible. Large claim data must include: age, sex, diagnosis, prognosis, treatment plan, case management notes (if applicable), Pre -Cert and paid/pended claims. • The Estimated Contract Attachment Point includes the Aggregate Corridor level as shown. To determine Estimated Expected Claims, you may divide the Attachment Point or Attachment factors by the corridor level. • The specific rates in this proposal are based on an aggregating specific arrangement. Total Specific Liability includes estimated contract specific premium and the aggregating specific fund. • Human Organ Transplant benefits are payable in accordance with the underlying plan and are subject to the proposed Lifetime Maximum Specific Benefit offered within this proposal. apply to the Aggregating Specific Loss Fund. The rate cap does not apply to Material Changes, including but not limited to the following: • This proposal includes a 50% rate cap on the Specific Premium Rate at the renewal of your stop loss policy. If applicable, this increase will also underlying plan document, our stop loss contract provisions, PPO network or TPA, and the rates may be further adjusted by such changes. The rate cap rider applies to this policy term only. It may be offered at subsequent stop loss policy renewals at the discretion of Underwriting. At renewal we will not apply any new Special Risk Limitations including but not limited to an Alternate Specific Deductible or Excluded Claim Expense unless requested. PROPOSAL ACCEPTANCE Leave of Absence (LOA) Policy for eligible employees is: _ Days orWeeks or year per member and only after FMLA allowance is exhausted. Leave Of Absence allowance need not be used rin consecutive daysand it is to be , but total tid once perme not actively at work during the plan year as a whole must not exceed the above outlined allowance plus the 90 day FMLA allowance. In the absence of Leave of Absence language in the group plan document, the above will be considered as the LOA policy as it relates to Stop Loss Eligibility and continuation of coverage only. Any subsequent changes must be approved by Florida Blue at least 30 days in advance of the effective date of the change. Failure to notify Florida Blue of your company's policy changes for Leave of Absence may result in a possible Stop Loss claim denial. Upon exhaustion of LOA benefits as described above, to continue Stop Loss eligibility members must be offered COBRA as outlined in the "Continuation of Coverage Under Cobra" section in your Group Benefit Book. All other eligibility requirements beyond the LOA allowance described here are outlined in the Group Benefit Book and apply to the Stop Loss in their entirety. Please acknowledge acceptance of the terms in this proposal by signing and returning by 08/28/2021 (no signed proposal will be accepted after the effective date). Please also indicate which option is chosen and whether Aggregate is to be included, by checking the appropriate boxes on the previous page. Failure to remit the signed agreement within the same period will result in updated large claim disclosure (and claims) being required for our review. All payments after the effective date of this polip. AYY/ikprevious page, must use the rates selected. Any deviation from the rates specified could result in an underpayment leading to ' li; Pofic • "Nation. �/A �_ _"I Fn • i r Signature: " the 21st day of Sept 2021 Underwriter: KMC (August 2, 2021) 10816062764-2021-609536-4-4 Attest: Jeffrey R. Smith, Clerk of Circuit Court and Comptroller Deputy Clerk Page 2 of 6