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F&P4& B&e .•. d <br />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 Couoy Comm <br />Specific Deductible (per Covered Participant) <br />Policy Year Maximum Specific Benefit <br />$375,000 <br />$400,000 <br />Lifetime Maximum Specific BenefitUnlimited <br />ited <br />Covered Benefits <br />ited <br />Unlimited <br />Specific Premium <br />ard <br />Med, Rx Card <br />Composite Rate 1.58 <br />Total Lives$40.43 <br />1 <br />/96/12 <br />Estimated Contract Specific Premium <br />Contract Aggregating Specific Loss Fund00 <br />383 <br />$810,217 <br />Contract Basis <br />-$100,000 <br />Commission0%0.00% <br />/12 <br />96/12 <br />Covered Benefits <br />Policy Year Maximum <br />Aggregate Factors <br />Composite Med, Rx Card Factor <br />Estimated Contract Attachment F <br />Estimated Contract Minimum Aft, <br />Aggregate Corridor <br />Contract Basis <br />Aggregate Premium <br />Composite Rate <br />Med, Rx Card <br />$1,000,000 <br />1,670 $1,506.18 <br />1,670 <br />Pnint /1Mo/1 <br />$30,183,847 <br />$30,183,847 <br />125% <br />96/19 <br />Med, Rx Card <br />$1,000,000 <br />$1,509.17 <br />$30,243,767 <br />$30,243,767 <br />125% <br />96/12 <br />Date: 10/01/2021 <br />Date: 09/30/2022 <br />i,biu $2.11 $2.13 <br />Estimated Contract ggregate Premium 1,670 $42,284 $42,685 <br />Commission . <br />000% <br />— — -- 0.00% <br />Total Combl d Estimated Contract Premium <br />-- $935,668 <br />— 852,902 <br />Note: T s proposal is not complete unless accompanied by the proposal notes and the basis of offer noted on the following pages. <br />ividual Special Requirements: <br />Underwriter: KMC (August 2, 2021) 10816062764-2021-609536-4-4 <br />Page 3 of 6 <br />