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Florida, Mete <br />An Independent Licensee of the <br />Blue Cross and Blue Shield Association <br />STOP LOSS PROPOSAL FOR <br />Indian River County BOCC <br />PROPOSAL NOTES <br />• The rates and factors in this proposal are firm. Please provide a signed proposal, binder check and signed application. <br />• 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 <br />data must include: age, sex, diagnosis, prognosis, treatment plan, case management notes (if applicable), Pre -Cert and paid/pended claims. <br />• The specific rates in this proposal are based on an aggregating specific arrangement. Total Specific Liability includes estimated contract specific <br />premium and the aggregating specific fund. <br />• Human Organ Transplant benefits are payable in accordance with the underlying plan and are subject to the proposed Lifetime Maximum Specific <br />Benefit offered within this proposal. <br />PROPOSAL ACCEPTANCE <br />Please acknowledge acceptance of the terms in this proposal by signing and returning by 08/28/2015 (no signed proposal will be accepted after the <br />effective date). Please also indicate which option is chosen and whether Aggregate is to be included, by checking the appropriate boxes on the <br />previous page. Failure to remit the signed agreement within the same period will result in updated large claim disclosure (and claims) being required <br />for our review <br />Signature: <br />Accepted o <br />day of <br />Title: dean gjn)S7rtt*2Y'- <br />20)� y <br />APPROVED AS 70 FORM <br />AND LEGAL SUFFICIENCY <br />BY <br />DYLAN REINGOLD <br />COUNTY ATTORNEY <br />Underwriter REB (August 18, 2015) <br />10445852891-2015-420165-5-4 Page 2 of 4 <br />