2014-318 HR - UnitedHealthCare for United HealthCare Application for Excess Loss Insurance Policy $1,625,322

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■ Clerk to the Board's — wwv�! to the _please return this c epmanent agenda file o office for p UNITEDHEALTHCARE INSURANCE COMPANY A Stock Company 185 Asylum Street,Hartford,Minnesota Phone: 1-860-702-5000 APPLICATION FOR EXCESS LOSS INSURANCE The undersigned Applicant requests the Excess Loss Insurance Benefits shown herein and provided by UnitedHealthcare Insurance Company,and agrees to be bound by the terms and provisions of the Excess Loss Insurance Policy. Full Legal Name of Applicant: Orange County Address: 200 South Cameron Street,Hillsborough,NC 27278 Key Contact: Diane Shepherd Telephone: 919-245-2558 Tax ID: Applicant is a: Local Government Nature of Business of the Group to be Insured: Local Government Requested Effective Date: January 1,2014 Total number of eligible persons: Employees: 869 Retirees: 153 Are retirees covered: Y Agent or Broker: Mark III Brokerage Inc. SS No.or Tax ID: Address: 211 Greenwich Road,Charlotte,North Carolina 28211 SPECIFIC EXCESS LOSS INSURANCE: Benefit Period:Covered Expenses Incurred from January 1,2014 through December 31,2014,and Paid from January 1,2014 through December 31,2014. Specific Deductible per Covered Person: $100,000 Specific Percentage Reimbursable: 100% Maximum Specific Benefit per Covered Person:Unlimited Covered Expenses Under Specific Excess Loss: • Medical • Stand Alone Prescription Drug Program Specific Excess Loss Premium: $88.80 per subscriber per month AGGREGATE EXCESS LOSS INSURANCE Benefit Period:Covered Expenses Incurred from January 1,2014 through December 31,2014,and Paid from January 1,2014 through December 31,2014. Covered Expenses under Aggregate Excess Loss Coverage: • Medical • Stand Alone Prescription Drug Program Aggregate Percentage Reimbursable: 100% Maximum Aggregate Benefit: $2,000,000 per Policy Year UHIAPP(12/01)