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FRAUD NOTICE (Please read carefully)• .: In Florida, any person who knowingly and with intent to injure, defraud or deceive any insurer files a statement of claim for an application containing any false, incomplete or misleading information is guilty of a felony of the third degree APPLICANT UNDERSTANDS AND AGREES THAT The stop loss insurance requested and requested effective date must be approved by Florida Blue as under our current rules and practices All options and special requests are subject to approval from HM Life Insurance Company, administrator for Florida Blue No insurance agent or broker has authority to guarantee acceptability of requested insurance coverage. Our approval is subject to receipt of Disclosure Statement, the first month's premium, final census, and any other information requested in connection with this application. Failure to do so will result in approval being denied or delayed until a later date Receipt of a premium and its deposit in connection with the Application shall not constitute an acceptance of liability In the event that Florida Blue, or our authorized agent, disapproves this Application, its sole obligation shall be to refund such sum to the Applicant. Coverage will not be in effect until notified in writing from HM Life Insurance Company, administrator for Florida Blue. Do not cancel prior coverage until so notified. Final premium rates will be determined on the basis of Disclosure Statement, Claim Information and the actual composition of persons covered by the underlying employee benefit plan on the requested effective date Should subsequent information become known which, if known as of the date specified by Florida Blue, or our authorized agent, would have affected the rates, deductibles, terms or conditions for coverage, we will have the right to revise the rates, deductibles, terms or conditions, by providing written notice to the Applicant. The Policy, if issued, may be void, if whether before or after a claim or loss, any material fact or circumstance was concealed or misrepresented on behalf of the Applicant, or if the Applicant or its Agent, committed fraud A signed and dated summary plan document describing the underlying employee medical plan must be submitted within 60 days of the Requested Effective Date to HM Life Insurance Company, administrator for Florida Blue. If the description of the benefits or plan provisions differs from what was initially utilized to underwrite the risk, the premium rates and aggregate retention factors may be subject to re -rating, retro -active to the requested effective date The stop loss insurance which is the subject of this Application is a reimbursement contract, and the Applicant must first pay claims and make funds available to pay claims as they become payable before submitting them for reimbursement. Oral statements not expressly incorporated herein are not part of this Application. Issuance of the Policy is in reliance of the data, including Disclosure Statement, census and Claim Information, submitted to us, and payment of the first month's premium, subsequent premiums are due no later than the first day of each calendar month during the Plan Year I represent that the statements contained in this application are true and complete to the best of my knowledge and belief, and I understand that they form the basis for Florida Blue's approval of the requested stop loss insurance. Joseph A. Baird Printed Name of Applicant's Authorized R C/�l �/.6Qf J +'�2XJ i resentative 10/05/2015 County Administrator Signgti