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An Independent Licensee of the STOP LOSS PROPOSAL FOR <br />Blue Cross and Blue Shield Association Indian River County Board <br />Sales Representative: George Eppl <br />Proposed Effective Date: <br />10/01/2024 <br />Broker: LOCKTON COMPANIES LLC <br />Through Date: <br />09/30/2025 <br />Claims Administrator: Blue Cross Blue Shield of South Carolina <br />RFP Situs State: <br />FL <br />Provider Network(s): BCBS of SC <br />Utilization Review Vendor(s): Blue Cross Blue Shield of South Carolina <br />Retirees: Both Medicare Retirees and Under 65 Retirees Included <br />Specific (Check one option) Lives 0 Opflon <br />I r,4 Option <br />2 <br />0 Option 3 0 Oplion <br />4 <br />Specific Deductible (per Covered Participant) <br />$275,000 <br />$300,000 <br />$325,000 <br />$350,000 <br />Policy Year Maximum Specific Benefit <br />Unlimited <br />Unlimited <br />Unlimited <br />Unlimited <br />Lifetime Maximum Specific Benefit <br />Unlimited <br />Unlimited <br />Unlimited <br />Unlimited <br />Eligible Claims Expenses <br />Med, Rx <br />Med, Rx <br />Med, Rx <br />Med, Rx <br />Specific Premium <br />Composite Rate 1,699 <br />$56.95 <br />$52.42 <br />$46.34 <br />$42.57 <br />Total Lives 1,699 <br />Estimated Policy Term Specific Premium <br />$1,161,097 <br />$1,068,739 <br />$944,780 <br />$867,917 <br />Policy Term Aggregating Specific Loss Fund <br />$100,000 <br />$100,000 <br />$100,000 <br />$100,000 <br />Specific Covered Claims Basis <br />36/12 <br />36/12 <br />36/12 <br />36/12 <br />Commission <br />0.00% <br />0.00% <br />0.00% <br />0.00% <br />Specific Coverage Features/Options <br />Accelerated Reimbursement <br />Rate Cap <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: TLR (August 15, 2024) 11391839286-37516-2-2 Page 1 of 4 <br />