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F& r4& B& (e 0 C1 <br />An Independent Licensee of the <br />Blue Cross and Blue Shield Association <br />STOP LOSS PROPOSAL FOR <br />Indian River County Board <br />HIPAA Privacy rules permit the release of Protected Health Information (PHI) for the purpose of evaluating and accepting risk associated with the <br />Plan Sponsor as part of "Health Care Operations." HM will use this information solely for the purpose of evaluating and accepting the risk and will <br />not disclose any PHI collected except to perform this risk evaluation. <br />The rates in this proposal are based on the Disclosure of all individuals considered a special enrollee due to having previously satisfied the plan's <br />lifetime maximum. Written acceptance by HM must be acknowledged before terms of coverage for such individuals are included under HM's Stop <br />Loss Policy. <br />Any Stop Loss Policy issued by HM may be rescinded or re -underwritten if any information requested in connection with this proposal was <br />intentionally concealed or misrepresented by or on behalf of the Policyholder and/or the Policyholder's Agent, or if the Policyholder and/or the <br />Policyholder's Agent commits fraud. <br />As used above: An "Agent" is the prospective Policyholder's representative including, but not limited to, the agent, producer or broker of record, or <br />Claims Administrator. A "Claims Administrator" is a third -party administrator (TPA) designated by the Policyholder and approved by Us. Disclosure <br />or Disclosed means to provide Claim Information and any other documentation or data requested by Us including, but not limited to, Census and <br />Demographic Information and the estimated number of Covered Units prior to the beginning of the Policy Term. <br />Coverage is underwritten by Florida Blue, Jacksonville, FL and is administered by HM Life Insurance Company, Pittsburgh, PA. HM Life Insurance <br />Company is an independent company providing only administrative services. <br />Underwriter: TLR (August 15, 2024) 11391839286-37516-2-2 Page 4 of 4 <br />