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An Independent Licensee of the STOP LOSS PROPOSAL FOR Blue Cross and Blue Shield Association Indian River County Board PROPOSAL NOTES • The rates in this proposal are firm. Please provide a signed proposal and signed application. 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 Specific rates in this proposal are based on an Aggregating Specific arrangement. Maximum Specific Liability includes estimated Policy Term Specific premium and the Aggregating Specific fund. This proposal includes Accelerated Reimbursement. Human Organ Transplant benefits are payable in accordance with the Covered Underlying Plan and are subject to the proposed Lifetime Maximum Specific Benefit offered within this proposal. This proposal includes a 40% rate cap on the Specific Premium Rate at the renewal of your Stop Loss Policy. If applicable, this increase also will apply to the Aggregating Specific Loss Fund. The rate cap does not apply to Material Changes including, but not limited to, the following: Covered Underlying Plan, HM's Stop Loss Policy provisions, the PPO network or the Claims Administrator, 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 HM Underwriting. At renewal, We will not apply any new lasers, including but not limited to, an Alternate Specific Deductible or Excluded Claim Expense, within the Special Risk Limitations section of the policy, unless requested. Lockton's standard required terms will not be automatically accepted. However, a Stop Loss Acknowledgement Form may be requested at the time of sale. PROPOSAL ACCEPTANCF To consider a group for coverage we will require submission of all underlying documentation regarding member eligibility and termination as well as the group Leave of Absence Policy. If there is no Leave of Absence Policy in place, we will require a statement from the Plan Sponsor stating there is no Leave of Absence available. Additionally, we will require an approved benefit book within 60 days of Benefit Book release by FL Blue for group approval. Please acknowledge acceptance of the terms in this proposal by signing and returning by 09/13/2024. Please also indicate which option is chosen by checking the appropriate box on the previous page. Failure to remit the signed agreement by 09/13/2024 will result in this prppo.M1 being considered expired. C0ht4��ss. Signature: title.•' Accepted on the 10th day of Sept 20 2 4 . COUNTY• APPROVED AS TO FORM AND LEG SUFFiCI'" Y BY .P O DEPUTY COUNTY ATTORNEY Attest: Ryan L. Butler, Clerk of Circuit Court and Comptroller c— By: eputy ca Coverage is underwritten by Florida Blue, Jacksonville, FL and is administered by HM Life Insurance Company, Pittsburgh, PA, HIM Life Insurance Company is an independent company providing only administrative services. Underwriter: TLR (August 15, 2024) 11391839286-37516-2-2 Page 2 of 4