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DocuSign Envelope ID: 5332467E-CBEF-4C5D-8BOE-61 E380BDAl 1 B <br />DocuSign Envelope ID: 151ECOCF-B55C-414F-9455-72004347A310 <br />(1/2023 Version) <br />EXHIBIT A <br />CLIENT APPLICATION <br />January 1, 2023 <br />[IMPORTANT — PLEASE READ CAREFULLY: Client should complete Section A and <br />carefully review this Exhibit A. which has been completed by Administrator, in order to <br />ensure the accuracy and completeness of such information. Client shall promptly notify <br />Administrator of any inaccuracy or omission with respect to such terms and conditions, if <br />applicable (including, without limitation, the Client Information in Section A).] <br />A. CLIENT INFORMATION <br />Client's Name: Indian River County Board of County Commissioners <br />Client's Mail Address: 1801 27th Street, Vero Beach, Florida 32960-3365, United States <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 (a) any failure to <br />implement Plan Design changes which are not communicated in writing to Administrator, or (b) implementation of <br />verbal or written direction regarding exception or overrides to the PDD. In addition, Client shall notify Members of <br />any Plan Design changes prior to the effective date of any such changes as required by applicable law. <br />NOT FOR DISTRIBUTION. THE INFORMATION CONTAINED HEREIN IS CONFIDENTIAL, PROPRIETARY <br />AND CONSTITUTES TRADE SECRETS OF ESI AND RXBENEFITS <br />