2015-393-E HR - UnitedHealthCare (UHC) for UHC Application for Excess Loss Insurance Policy $1,265,095

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DocuSign Envelope ID: EE765B38-37EF-4402-B4E9-8B82F98E2EE8 UNITEDHEALTHCARE INSURANCE COMPANY A Stock Company 185 Asylum Street,Hartford,Connecticut 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: July 1,2015 Total number of eligible persons: Employees: 869 Retirees: 153 Are retirees covered: Y Agent or Broker: Arthur J. Gallagher&Company SS No.or Tax ID: Address: 4064 Colony Road, Suite 450,Charlotte,North Carolina 28211 SPECIFIC EXCESS LOSS INSURANCE: Benefit Period: Covered Expenses Incurred from January 1,2014 through June 30,2016,and Paid from July 1,2015 through June 30, 2016. 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: $107.03 per subscriber per month It is understood and agreed by the undersigned that: a. The statements,declarations and representations made in this Application,any request for proposal,the underwriting information provided by or on behalf of the undersigned and the Plan Document are the undersigned's representations; that any Policy is issued in reliance upon the truth of such statements,declarations, and representations; and that such statements,declarations,and representations will form a part of the Excess Loss Insurance Policy. Any inaccuracy in such information or failure to disclose any such information, including all claims or possible claims, paid or pending, or which the Employer should otherwise know about,if discovered later,can result in rejection of this Application,or can change the terms,conditions or premiums,or can void coverage. b. As a condition precedent to the approval of this Application, the undersigned shall furnish to the Company a copy of the executed Plan Document within 90 days after the date of this application describing the benefits provided by the Plan, which shall be kept on file in the office of the Company. If the Company does not receive the Plan Document within 90 days, the UHIAPP(12/01)