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Florida,Blue �t d <br />An Independent Licensee of the <br />Blue Cross and Blue Shield Association <br />STOP LOSS PROPOSAL FOR <br />Indian River County BOCC <br />Sales Representative: <br />Broker: <br />TPA: <br />Provider Network(s): <br />Utilization Review Vendor(s): <br />George Eppl <br />Gehring Group <br />Florida Blue <br />Florida Blue <br />Florida Blue <br />Effective Date: 10/01/2015 <br />Through Date: 09/30/2016 <br />Specific Deductible (per Covered Individual) <br />Policy Year Maximum Specific Benefit <br />Lifetime Maximum Specific Benefit <br />Covered Benefits <br />Specific Premium <br />Composite Rate <br />Total Lives <br />Estimated Contract Specific Premium <br />Contract Aggregating Specific Loss Fund <br />Contract Basis <br />Commission <br />75;00 <br />nlirimited <br />,U ed <br />;Raard <br />}`$300;01)0` <br />'Unlimited• <br />,Unlimited <br />• <br />ar: " <br />Nled=Rz .Card <br />1,565 <br />1,565 <br />536;545. <br />;00%`i' <br />464993: <br />148,750;. <br />Aggregate: (Include?Yes 1 -No) <br />Covered Benefits <br />Policy Year Maximum <br />Aggregate Factors <br />Composite Med & Rx Card Factor 1,565 <br />Estimated Contract Attachment Point 1,565 <br />Contract Minimum Attachment Point (100%) <br />Aggregate Corridor <br />Contract Basis <br />Aggregate?remium <br />Composite Rate 1,565 <br />Estimated Contract Aggregate Premium 1,565 <br />Commission <br />Total Combined Estimated Contract Premium <br />,Rx'Card``, _•_' Med; Rx Card <br />1;000,000x: " -P , $1,000;00_d <br />t $1;00153' <br />$18;808;733;`:;~�".$.18;902;824 <br />,�'.=24%12•: <br />ed; RxCard <br />x.1;000,000• <br />$1,006:54„l§, <br />$18 902,821'_! <br />25% <br />4/12:2 <br />$1;41T.�r:��•�,. - �'b� $1:44 <br />126„480 '``.`i x{4 • $27,043 • <br />-10:00%%'.10:00%`1 <br />$563,024 $492,036 <br />1;010:54" <br />18;977441, <br />$18;977;94:1 `T 4/12 <br />$27;607 • <br />10;00% <br />$441,142 <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 REB (.At:cust 18 20151 10445852891-2015-420165-5-4 <br />Page 1 o14 <br />