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An Independent Licensee of the STOP LOSS PROPOSAL FOR <br />Blue Cross and Blue Shield Association Indian River County Board <br />Sales Representative: George Eppl <br />Proposed Effective Date: <br />10/01/2025 <br />Broker: LOCKTON COMPANIES LLC <br />Through Date: <br />09/30/2026 <br />Claims Administrator: Blue Cross Blue Shield of South Carolina <br />RFP Situs State: <br />FL <br />Provider Network(s): Blue Cross Blue Shield of South Carolina <br />Utilization Review Vendor(s): Blue Cross Blue Shield of South Carolina <br />Retirees: Both Medicare Retirees and Under 65 Retirees Included <br />Specific (Check one .. <br />Option 1 Option <br />Specific Deductible (per Covered Participant) $300,000 <br />$300,000 <br />$325,000 <br />$350,000 <br />Policy Year Maximum Specific Benefit Inforce <br />Unlimited <br />Unlimited <br />Unlimited <br />Lifetime Maximum Specific Benefit Inforce <br />Unlimited <br />Unlimited <br />Unlimited <br />Eligible Claims Expenses Med, Rx <br />Med, Rx <br />Med, Rx <br />Med, Rx <br />Specific Premium <br />Composite Rate 1,724 $52.42 <br />$56.67 <br />$50.17 <br />$47.77 <br />Total Lives 1,724 <br />Estimated Policy Term Specific Premium $1,084,465 <br />$1,172,389 <br />$1,037,917 <br />$988,266 <br />Policy Term Aggregating Specific Loss Fund $100,000 <br />$100,000 <br />$100,000 <br />$100,000 <br />Specific Covered Claims Basis 36/12 <br />48/12 <br />48/12 <br />48/12 <br />Commission 0.00% <br />0.00% <br />0.00% <br />0.00% <br />Specific Coverage Features/Options <br />Rate Cap <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 />• Firm through 08/20/2025. <br />Underwriter: KW (July 21, 2025) 11611394256-78346-5-1 Page 1 of 4 <br />