Addendum_1_2026_stoploss_contract.pdf

STOP LOSS PROPOSAL FOR

City of Sarasota

Underwriter: KW (October 15, 2025) 11698906901-91867-3-1 Page 1 of 5

Specific (Check one option) Lives Current Renewal

Specific Deductible (per Covered Participant) $250,000 $250,000

Policy Year Maximum Specific Benefit Inforce Unlimited

Lifetime Maximum Specific Benefit Inforce Unlimited

Eligible Claims Expenses Med, Rx Med, Rx

Specific Premium

Composite Rate 876 $83.28 $124.92

Total Lives 876

Estimated Policy Term Specific Premium $875,439 $1,313,159

Specific Covered Claims Basis 24/12 36/12

Commission 0.00% 0.00%

Aggregate (Agg) (Include? Yes No)

Eligible Claims Expenses Med, Rx Med, Rx

Policy Year Maximum $2,000,000 $2,000,000

Aggregate Factors

Composite Medical, Rx Factor 876 $1,696.23

Estimated Policy Term Agg Deductible 876 $17,472,672 $17,830,770

Estimated Policy Term Minimum Agg Deductible (100%) $17,472,672 $17,830,770

Aggregate Corridor 125% 125%

Aggregate Covered Claims Basis 24/12 36/12

Aggregate Premium

Composite Rate 876 $3.87 $4.81

Estimated Policy Term Agg Premium 876 $40,681 $50,563

Commission 0.00% 0.00%

Total Combined Estimated Policy Term Premium $916,120 $1,363,722

Note: This proposal is not complete unless accompanied by the proposal notes and the basis of offer noted on the following pages.

Individual Special Requirements:

• Firm through 10/24/2025.

Sales Representative: Robin MacDonald Proposed Effective Date: 01/01/2026 Broker: Brown & Brown Insurance Services, Inc Through Date: 12/31/2026 Claims Administrator: Blue Cross Blue Shield of South Carolina RFP Situs State: FL Provider Network(s): Blues Utilization Review Vendor(s): Blue Cross Blue Shield of South Carolina Retirees: Only Under 65 Retirees Included

Coverage is underwritten by Florida Blue, Jacksonville, FL and is administered by HM Life Insurance Company, Pittsburgh, PA. HM Life Insurance Company is an independent company providing only administrative services.

Underwriter: KW (October 15, 2025) 11698906901-91867-3-1 Page 2 of 5

PROPOSAL NOTES

• The rates and factors in this proposal are firm. Please provide a signed proposal.

• 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 data must include age, sex, diagnosis, prognosis, treatment plan, case management notes (if applicable), Pre-Cert and paid/pended claims.

• The Estimated Policy Term Aggregate Deductible includes the Aggregate Corridor level as shown. To determine Estimated Expected Claims, you may divide the Aggregate Deductible or Aggregate factors by the corridor level.

• Human Organ Transplant benefits are payable in accordance with the Covered Underlying Plan and are subject to the proposed Lifetime Maximum Specific Benefit offered within this proposal.

• At renewal, We will not apply any new lasers, including but not limited to, an Alternate Specific Deductible or Excluded Claim Expense, within the Special Risk Limitations section of the policy, unless requested.

• Only retirees under age 65 are included in the stop loss coverage.

• Florida Blue follows the underlying Plan Document, subject to the Exclusions and Limitations of the Stop Loss Policy.

• An up to date, signed and complete Summary Plan Document is required for claims to be eligible for reimbursement.

• This proposal is subject to large claim evaluation. This will determine whether any individuals need to be set at a specific deductible higher than the group level.

• Notwithstanding any other terms or conditions, the following provisions shall apply to gene therapies:

• No new laser (including, but not limited to, an alternate specific deductibles or excluded claim expenses) will be applied to any individual at the next renewal for gene therapy costs.

• Rates and aggregate specific deductibles, if applicable, will not increase at renewal due to gene therapy claim costs.

• Any lasers and/or contingencies in place as of the proposal effective date may be continued on subsequent renewals, subject to the carrier's discretion.

• The carrier reserves the right to offer, modify, or discontinue these provisions on subsequent renewals.

• These provisions do not supersede the group's plan documents in determining eligibility for gene therapy coverage and do not apply to gene therapy claims deemed ineligible for coverage.

• The specific deductible and any pre-existing lasers remain applicable.

• These provisions apply exclusively to the costs of the gene therapy itself and do not extend to costs associated with underlying conditions, comorbidities, or other medical expenses related to the treatment or management of such conditions.

Coverage is underwritten by Florida Blue, Jacksonville, FL and is administered by HM Life Insurance Company, Pittsburgh, PA. HM Life Insurance

Underwriter: KW (October 15, 2025) 11698906901-91867-3-1 Page 3 of 5

PROPOSAL ACCEPTANCE

To consider a group for coverage we will require submission of all underlying documentation regarding member eligibility and termination as well as the group Leave of Absence Policy. If there is no Leave of Absence Policy in place, we will require a statement from the Plan Sponsor stating there is no Leave of Absence available. Additionally, we will require an approved benefit book within 60 days of Benefit Book release by FL Blue for group approval.

Please acknowledge acceptance of the terms in this proposal by signing and returning by 10/24/2025. Please also indicate which option is chosen and whether Aggregate is to be included by checking the appropriate boxes on the previous page. All payments after the effective date of this policy, found on the previous page, must use the rates selected. Any deviation from the rates specified could result in an underpayment leading to a possible policy cancellation.

Failure to remit the signed agreement by 10/24/2025 will result in this proposal being considered expired.

Signature: __________________________________________ Title: __________________________________________

Accepted on the _______________ day of ___________, 20__________

Coverage is underwritten by Florida Blue, Jacksonville, FL and is administered by HM Life Insurance Company, Pittsburgh, PA. HM Life Insurance

Underwriter: KW (October 15, 2025) 11698906901-91867-3-1 Page 4 of 5 initials: _______ date: _________

BASIS OF OFFER

Assumptions

• Aggregate coverage is only available when purchased with Specific coverage.

• This proposal is subject to revision if there is a change in Proposed Effective or Renewal Dates or a change in the Covered Underlying Plan.

• This proposal is based on the utilization of the Provider Network(s) and the Utilization Review Vendor(s) listed in this proposal.

• This proposal assumes a minimum participation level of 50%.

• This proposal assumes the Covered Underlying Plan includes a pre-certification, utilization review and large case management program.

• This proposal is based on a description of the employee benefit plan(s) provided and approved by Florida Blue; employee and dependent census data; and any other information relevant to the underwriting risk. If any of the information was incorrect or changes the risk involved, the rates and factors will be modified, and the Specific and Aggregate claims will be adjusted accordingly.

• Surcharges (including the bad debt and charity surcharge portion of the New York Reform Act applicable to services are rendered in New York State), pool charges, and/or covered lives assessments may be covered under the Stop Loss Policy if such charges are considered a claim cost.

Florida Blue is not responsible for the filing and/or payment of any assessment for which Florida Blue is not directly liable including, but not limited to, the New Hampshire Vaccine Assessment as modified by NH HB 664.

• All standard policy provisions apply. The laws of the state where the policy is issued will apply. Certain exclusions and limitations may apply.

• The terms of this proposal are subject to revision if there is a change in any state law or regulation between the date of this proposal and the effective date of the proposed Stop Loss coverage if such changes are deemed to have a material effect on the risk being assumed.Such a revision can be made even if the proposal has already been accepted.

• This proposal will expire on the Proposed Effective Date.

• The dollar value of the minimum deductible shown above is representative. The actual value of the minimum deductible will be calculated according to the terms of the Stop Loss Policy.

• Unless otherwise limited or excluded by the Stop Loss Policy or under the Individual Special Requirements, Eligible Claim expenses under the Stop Loss Policy will follow the Covered Underlying Plan, up to the proposed Maximum Specific Benefit.

• The Agent is properly licensed and appointed by Florida Blue.

• The initial rates are guaranteed for the proposed Policy Term unless otherwise noted.

• There are no more than 15% COBRA participants.

Qualifications

• Any Stop Loss insurance requested and the Proposed Effective Date of that coverage must be approved by The Company under Our current rules and practices.

• Both the premium rates and the Aggregate factors are subject to change should the number of Covered Units change by 10% or more, either in total and/or by single/family mix.

• If the descriptions of the benefits or plan provisions differ from what was initially utilized to underwrite the risk, an updated Summary Plan Document or other acceptable plan description is required within 60 days of the Effective Date, and the premium rates and Aggregate factors may be subject to re-rating, retro-active to the Effective Date.

• This quote assumes the Covered Underlying Plan will include standard industry provisions and definitions including, but not limited to, eligibility, HIPAA, termination, leave of absence or disability, FMLA, subrogation, transplants and COB and exclusions for job-related injuries, treatments that are experimental and/or investigational, cosmetic, not medically necessary, war, felonies, charges in excess of usual and customary, and foreign medical care when traveling outside of the U.S. solely for the purpose of receiving medical care. In the event that a Summary Plan Document is not available within 60 days from the Proposed Effective Date, We reserve the right to issue the policy assuming standard exclusions will apply.

Coverage is underwritten by Florida Blue, Jacksonville, FL and is administered by HM Life Insurance Company, Pittsburgh, PA. HM Life Insurance

Underwriter: KW (October 15, 2025) 11698906901-91867-3-1 Page 5 of 5

• HIPAA Privacy rules permit the release of Protected Health Information (PHI) for the purpose of evaluating and accepting risk associated with the Plan Sponsor as part of "Health Care Operations." Florida Blue will use this information solely for the purpose of evaluating and accepting the risk and will not disclose any PHI collected except to perform this risk evaluation.

• The rates and factors in this proposal are based on the Disclosure of all individuals considered a special enrollee due to having previously satisfied the plan's lifetime maximum. Written acceptance by Florida Blue must be acknowledged before terms of coverage for such individuals are included under Florida Blue's Stop Loss Policy.

• Any Stop Loss Policy issued by Florida Blue may be rescinded or re-underwritten if any information requested in connection with this proposal was intentionally concealed or misrepresented by or on behalf of the Policyholder and/or the Policyholder's Agent, or if the Policyholder and/or the Policyholder's Agent commits fraud.

• As used above: An "Agent" is the prospective Policyholder's representative including, but not limited to, the agent, producer or broker of record, or Claims Administrator. A "Claims Administrator" is a third-party administrator (TPA) designated by the Policyholder and approved by Us. Disclosure or Disclosed means to provide Claim Information and any other documentation or data requested by Us including, but not limited to, Census and Demographic Information and the estimated number of Covered Units prior to the beginning of the Policy Term.