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An Independent Licensee of the Blue Cross and Blue Shield Association PROPOSAL NOTES STOP LOSS PROPOSAL FOR Indian River County Board • The rates in this proposal are firm. Please provide a signed proposal. • 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. • 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. • Notwithstanding any other terms or conditions, the following provisions shall apply to gene therapies: No new laser (including, but not limited to, an alternate specific deductibles or excluded claim expenses) will be applied to any individual at the next renewal for gene therapy costs. Rates and aggregate specific deductibles, if applicable, will not increase at renewal due to gene therapy claim costs. Any lasers and/or contingencies in place as of the proposal effective date may be continued on subsequent renewals, subject to the carrier's discretion. The carrier reserves the right to offer, modify, or discontinue these provisions on subsequent renewals. These provisions do not supersede the group's plan documents in determining eligibility for gene therapy coverage and do not apply to gene therapy claims deemed ineligible for coverage. The specific deductible and any pre-existing lasers remain applicable. These provisions apply exclusively to the costs of the gene therapy itself and do not extend to costs associated with underlying conditions, comorbidities, or other medical expenses related to the treatment or management of such conditions. PROPOSAL ACCEPTANCE 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 08/20/2025. Please also indicate which option is chosen by checking the appropriate box on the previous page. All payments after the effective date of this policy, found on the previous page, must use the rates selected. Any deviation from the rates specified could result in„a!r04rp ent leading to a possible policy cancellation. Failure to remit t e signed greement by 08/20/2025 will resuff ilhvAlt; prppos4gi9jng considered expired. Signature: G` itle: ai rt:m mow. s' cn APPROVED AS TO FORM AND GSUFFICIENCY Accep on the 19th day of August 20 �;�� Coverages underwritten by Florida Blue, .Jacksonville, FL and is administered by HM Life Insu Company is an independent company providing only administrative services. PHER A. HICKS OUNTY ATTORNEY pany, Pittsburgh, PA. HM Life Insurance Underwriter: KW (July 21, 2025) 11611394256-78346-5-1 Page 2 of 4