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THIRD PARTY ADMINISTRATOR (TPA) <br />Full Legal Name of TPA <br />Florida Blue <br />Tax ID Number <br />Business Telephone Number <br />904-905-1723 <br />Fax Number <br />904-565-6346 <br />Address <br />4800 Deerwood Campus Parkway DCC 300-5 <br />City <br />Jacksonville <br />State <br />FL <br />Zip Code + 4 <br />32246 <br />Delivery Address (if different than above) <br />City <br />State <br />Zip Code + 4 <br />Key Contact Person <br />Lena Polomsky <br />Internet <br />Email Address <br />Jena polomsky@floridablue com <br />PRODUCER (Agent/Broker) <br />Name <br />The Gehring Group/Kurt Gehring <br />License Number(s) — Please attach a copy, if not on file. <br />A094973 <br />Tax ID Number <br />65-0361295 <br />Business Telephone Number <br />561-626-6797 <br />Fax Number <br />561-626-6970 <br />Email <br />brian.beatty@gehringgroup.com <br />Internet <br />Address <br />11505 Fairchild Gardens Ave Suite 202 <br />City <br />Palm Beach Gardens <br />State <br />FL <br />Zip Code + 4 <br />33410 <br />Requested Effective Date <br />October 1, 2015 <br />Estimated Initial Enrollment: <br />Single: <br />Family <br />. <br />Total: <br />1565 <br />Premium Deposit of $ included. Estimated 1St month's premium must be attached to this application. The Premium Deposit will be <br />applied to the first premium when due. Make check payable to Florida Blue. Do not make the check payable to the agent or leave the "Payee" blank. If a <br />policy is not issued, the premium deposit will be refunded in full. <br />23717-608 (R6/13) <br />Page 2 of 3 Applicant's Initials: <br />