12. YourPPO Network is: Blue Cross Blue Shield
13. Your Utilization Review Provider is: Anthem
14. Eligible for coverage:
Retirees: Yes [X] No[ ] Late Entrants: Yes [ ] No [X] Other - Retirees Pre-65 Only: Yes[X]No[ ]
15. Estimated Covered Units:
Covered Unit Description Units
Composite 2050
16, Initial premium deposit accompanying this Application:
$154,693.00
17. COVERAGES
The Coverage shown applies only during the Policy Period from July 01, 2022 (Effective Date)
through June 30. 2023 (Expiration Date) and is further subject to all the provisions of the Policy.
A. SPECIFIC EXCESS LOSS COVERAGE [X] Yes, included [ } No, notincluded
1) Coverage to beincluded (not included unless checked):
[X] Medical [X] Prescription Drugs
2) Specific Attachment Point $350.000.00.
Per Covered Person.
* Specific Attachment point per covered personcannot be less than $31 000
3} Aggregating Specific Deductible: $0
NIA
4) Specific Policy Period Maximum Reimbursement Unlimited upon satisfaction of Specific
Attachment Point per Covered Person.
5) Basis of Specific Excess Loss coverage benefit payment {Benefit Period):
Plan Benefits incurred from July 01, 2021 through June 30. 2023 and
paid from July 01,2022 through June 30, 2023.
Plan Benefits Incurred prior to the Effective Date (Run-In-Period) will be limited to:
N/A per Covered Person
N/A for all Covered Persons combined
6) Premium Rates (per month):
Covered Unit Description Amount
Composite: 050 $75.46
7) Estimated Annual Specific Premium: $1,856,316.00.
B. AGGREGATE EXCESS LOSS INSURANCE [ ] Yes, Included [X] No, not included
1) Coverage to beincluded (not included unless checked):
[N/A] Medical [N/A] Prescription Drugs
2) Monthly Aggregate Factor: N/A
AH-MSL-1001-NH (11-21) © QBE, 2021 Page 2o0f 4
