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« If aggregate limits of less than $2,000,000 are imposed on bodily injury and property damage,
Contractor must maintain umbrella liability insurance of at least $1,000,000. All aggregates
must be fully disclosed on the required certificate of insurance.

« The specified insurance requirements do not relieve Contractor of its responsibilities or limit the
amount of its liability to the City or other persons, and Contractor is encouraged to purchase
such additional insurance, as it deems necessary.

« The insurance provided herein is primary, and no insurance held or owned by the City of Nashua
shall be called upon to contribute to a loss caused by Contractor.

* Contractor is responsible for and required to remedy all damage or loss to any property,
including property of the City, caused in whole or part by Contractor or anyone employed,
directed, or supervised by Contractor.

Regardless of any coverage provided by any insurance, Contractor agrees to indemnify and shall defend
and hold harmless the City, its agents, officials, employees and authorized representatives and their
employees from and against any and all suits, causes of action, legal or administrative proceedings,
arbitrations, claims, demands, damages, liabilities, interest, attorney’s fees, costs and expenses of any
kind or nature in any manner caused, occasioned, or contributed to in whole or in part by reason of any
negligent act, omission, or fault or willful misconduct, whether active or passive, of Contractor or of
anyone acting under its direction or control or on its behalf in connection with or incidental to the
performance of this contract. Contractor’s indemnity, defense and hold harmless obligations, or portions
thereof, shall not apply to liability caused by the sole negligence or willful misconduct of the party
indemnified or held harmless.

15

City of Nashua

Purchasing Department
Administrative Services Division (603) 589-3330
229 Main Street - Nashua, NH 03060 Fax (603) 594-3233

June 29, 2022
Memo #23-304

TO: Mayor Donchess
Finance Committee

SUBJECT: Excess Loss Insurance in the amount not to exceed $1,905,516 funded from 59165 Stop
Loss Coverage/Benefits Internal Service Fund

Please see attached communications from Kimberly Kleiner, Director of Administrative Services, dated June
27, 2022 for project specific details related to this purchase. Below please find a summary of the purchase
approval request:

Item: Stop Loss Insurance Coverage

Value: $1,856,316 for the annual premium, $49,200 for a one-time set up to total
$1,905,516

Vendor: QBE Insurance Corporation

Department: 113 Benefits
Source Fund: 59165 Stop Loss Coverage/ Benefits Internal Service Fund

Ordinance: Pursuant to § 5-78 Major purchases (greater than $25,000) A. All supplies and
contractual services, except as otherwise provided herein, when the estimated
cost thereof shall exceed $25,000 shall be purchased by formal, written contract
from the lowest responsible bidder, after due notice inviting bids.

The Administrative Services Division: Benefits Department, and the Purchasing Department respectfully
request your approval of this contract.

Regards,
Kelly Parkinson

Purchasing Manager

Ce: K Kleiner
J Graziano

Jim Donchess
Mayor e City of Nashua

To: Board of Aldermen

From: Mayor Jim Donchess

Date: June 29, 2022

Re: Contract Award in Excess of $1M-— Excess Loss Insurance Coverage

Pursuant to NRO: § 5-74/B: E. Approval by the Finance Committee of a contract award in excess of
$1,000,000 shall be submitted to the full Board of Aldermen at its next regularly scheduled meeting
for final approval prior to award of the contract.

The Finance Committee has approved and placed on file the notification of the award of the
referenced contract at the July 6, 2022 meeting and as such | am requesting the full Board of
Alderman approve the following contract:

Item: Stop Loss Insurance Coverage
Value: $1,856,316 for the annual premium, $49,200 for a one-time set up to
total $1,905,516
Vendor: QBE Insurance Corporation
Purchasing Memo#: 23-304 dated June 29, 2022
Contract Term: 7/1/22-6/30/23
Thank you.

229 Main Street * PO Box 2019 * Nashua, New Hampshire 03061-2019
603.589.3260 * fax 603.594.3450 * NashuaMayor@NashuaNH. gov
www.NashuaNH. gov

City of Nashua

Administrative Services Division

(603) 589-3020
229 Main Street - Nashua, NH 03060

To: Mayor Donchess
Finance Committee

Date: June 27, 2022
Re: Stop Loss Coverage FY23

This request is approval of a contract with QBE Insurance Corporation for the City of Nashua’s Excess
Loss Policy, otherwise known as Stop Loss.

Funding: Benefits Fund 13.6600.890-— 59615 Stop Loss Coverage $1,905,516.

For FY22 the City of Nashua contracted with Anthem Blue Cross Blue Shield for its annual Stop loss
coverage at an annual rate of $1,588,668. Upon notice of a substantial increase for FY23, the City
received bids through our broker, Workplace Benefit Solutions. QBE Insurance Corporation
Company, the lowest bidder, has offered the City comparable coverage at an annual premium of
$1,856,316 plus $49,200 for a set up and Stop Loss Interface fee, totaling $1,905,516. All other
terms will remain the same, including the claim threshold of $350,000. The current pricing is
dependent upon the number of participants, currently 2,050 at a rate of $75.46.

Currently there is $1,940,000 budgeted for FY23 in the Stop Loss Coverage Premium line of the
Benefits Fund.

Kimberly Kleiner
Administrative Services Division Director

Ce: K. Parkinson

Stop Loss Comparison for:

City of Nashua

For Effective Date: July 1, 2022 - June 30. 2023
Current Enrollment
First Pass Sinate 74S
350,000 ISL ng
$330,000 Ist Family 1,306
Total 2.050
Current Renewal! Propusuls
Anthem NY “enna CHT Y asm ens Fan @ QB Sun Life
HUB AY Berm nM” Sopra |® OBE.
Rave es Machel
$399,000 $350,000 $390.000 $V0,000 $350,000 $330,000 $599,000
° 24012 Spac 2442 Spec 2412 Spec 2412 Spec 24112 Spac 24.42 Spee 24/12 Spec
|Fixed Costs
Indrvidual Stop Lass rreneS o6sa s £395 $ rao} $ 9377 $ ~~ waasts 7540] 5 9545
Annual Premium $ 1.588.668 $ 7.065.170 $ 1.916064 1$ 2.291,982 $ 2,206,770 1$ 1.856.316] $ 7,340,464
Percent Change j 30.0% | 20.6% £8.3% 70.3% 16.8% 685%
Stop Loss Interface Fee™
recy § $ is 2c¢] 5 2M $ 200] $ 2.0915 260
Annual Premium 5 - $ -|$ 49.200 | $ $9.200 $ £9,200 | $ £9,200 | $ 49,200
|
Variable Costs(Lasers) |
Additonal Liability $ . |$ 675,000 $ - |s $ .
Total Premium and Livbility S 1,588,668 $ 2.065.170 $ 2.640,294]5 2.341.182 $ 2.753.970 $ 1.905.516] $ 2.389.604
Percent Chance 30.0% | 66.2% M.8% 73.5% 19.9% 72.1%
Notes:

1. Spreve and Vora desined $9 seve propasa's.
Pld Sou Cass lekerlone Fee ty moe wigs clacn reariag $0 Mad portly Wop 03s corners
f AY cropesais veinde 5% canmsson
4 SOG'S or oposer es frm and ven 7 aged fo aadian Cree meres 13 exauuiad from aloe 1068
5 OBL": propesat ss fen unt 9/7099 ard wader cB oces Ad omer propacals avo sahwoct so med.cal errow

2 Anion crerges a $277

QBE A&H

123 Pleasant Street, 3° Floor
Marblehead, MA 01945

Toli Free: 800.742.9279

qbeah.com

June 8, 2022

Beth Cutliffe

HUB International Limited
1667 Elm Street, Suite 3
Manchester, NH 03101

Dear Beth,
Re: Policy Issuance
Policyholder:

Policy Number:

QBE

City of Nashua, July 04, 2022
LGS02732-22

Thank you for selecting QBE Insurance Corporation for City of Nashua's Excess Loss Policy. We are pleased to have
the opportunity to service your client and hope to exceed your expectations.

Enclosed please find the appropnate documents for completion. In order to bind coverage, the following requirements

are needed.

e Signed and compieted Application for Excess Loss Policy
e First month’s premium: $154,693.00

e ACH Claims Reimbursement Authorization form for completion; Provides faster claim reimbursement
payment processing time, convenience, and security (ifinterested, please have this form completed and

return)

e State Required Licensing: The signing agent must be licensed in the state where the prospective client is
located, in the producer's resident state, and will need to be appointed with QBE where required.

e Executed Plan Documentinclusive of signature page which states all the provisionsof the plan and
delineates the various responsibilities for financing the plan, the eligibility, and all the other aspects of the
pian (summary descriptions and certificates alone are not acceptable).

e Welcome to Expedited Reimbursement Program Flyer

We are requesting the following reporting to please be sent at your earliest convenance.

e Finallargeclaims through the effective date to include 50% reportlisting name(s) & diagnosis. updated
trigger, pre-certification and case management reports inclusive of RX reporting.

The following Endorsement(s) modify the Excess Loss Policy and will be provided upon Policy Issuance.
e Advance Reimbursement Endorsement
e €xpedited Reimbursement Endorsement
e New Hampshire State Specific Endorsement
e Rate Stabilization Endorsement (50%)

QBE and the links logo are registered service marks of QBE Insurance Group Limited.

UND3005 (11-21)

Also enclosed is the Premium & Enrollment statement. Premium is due on the first of every month. Please note that
premium must be remitted directly to the PO BOX address listed on the Premium & Enrollmentstatement. A
completed copy ofthis statement should be remitted with each payment.

Please review the application and notify your underwriter of any requested changes priorto theclient's signature. We
will promptly re-issue the paperwork with any necessary changes. We appreciate your business partnership and the
opportunity to service the needs of our mutual client.

Please do nothesitate in contacting us with any questions or concerns.

If we can be offurther assistance with this group, please do not hesitate to contact either your underwriter or myself.

Regards,

Ernest Benard
Account Manager
QBE A&H

Cc: Lisandra Noto

UND3005 (11-21)

QBE QBE INSURANCE CORPORATION

STATE OF DOMICILE: PENNSYLVANIA

APPLICATION FOR EXCESS LOSS INSURANCE POLICY

Policy Number: LGS02732-22

1.

10.

11.

Full legal name of Policyhoider: Tax ID Number:
City of Nashua 02-6000581
(as it will appear in the Policy)

Principal Office Address:
229 Main Street Nashua, NH 03060

(street) (city) (state) (zip)
Contact Person: Kim Kleiner Email: kleinerk@nashuanh.gov

Nature of Business:9111 Executive Offices

if Employee Benefit Plans of subsidiary or affiliated companies (companies under common contro! through
stock ownership, contract, or otherwise) are to be included, list legal names and addresses of such
companies and the nature of their business:

Full name of Your Employee Benefit Plan:

A copy of Your Employee Benefit Plan Document, and those of any subsidiary or affiliated companies
that are to be included, must be attached to, and shall form a part of, this Application.

Effective Date: July 01, 2022

Endorsements:
Advance Reimbursement Endorsement AH-MSL-5013
Expedited Reimbursement Endorsement AH-MSL-5011-NH
New Hampshire Endorsement AH-MSL-5010-NH
Rate Stabilization Endorsement AH-MSL-5005

N/A

Your Designated Third Party Administrator (for purpose of claims administration under Your Employee
Benefit Plan):

Name: Anthem
Address: 1155 Elm Street
City, State, Zip: Manchester, NH 03101

Your broker/agent of record:

Name: HUB International Limited
Address: 1667 Elm Street, Suite 3
City, State, Zip: Manchester, NH 03101

AH-MSL-1001-NH (11-21) © QBE, 2021 Page 1 of 4

12.

13.
14.

15.

16.

17.

Your PPO Network is: Blue Cross Blue Shield

Your Utilization Review Provider is: Anthem

Eligible for coverage:

Retirees: Yes [X] No[ ] Late Entrants: Yes [ ] No [X]
Estimated Covered Units:
Covered Unit Description Units
Composite 2050

initial premium deposit accompanying this Application:
$154,693.00

COVERAGES

Other - Retirees Pre-65 Only: Yes [X] No[ ]

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
N/A

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
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.

. 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

and

AH-MSL-1001-NH (11-21) © QBE, 2021 Page 2 of 4

3) Estimated Annual Aggregate Attachment Point: N/A
* A. For Total Covered Units under51 employees, amount entered cannot be less thanthe greater of:
(1) $6,200 times the number of Covered Persons;
(2) 120% of expected claims; or
(3) $31,000.
B. For Total Covered Units over 50 employees, amount entered cannot be less than 110% of expected claims

4) Minimum Annual Aggregate Attachment Point Percentage: N/A
5) Estimated Minimum Annual Aggregate Attachment Point: N/A

6) Individual Claim Limit: N/A
Per Covered Person.

7) Aggregate Policy Period Maximum Reimbursement (per Policy Period): N/A
8) Basis of Aggregate Excess Loss coverage benefit payment (Benefit Period):

Plan Benefits Incurred from N/A through N/A
and paid from N/A through N/A.

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
9) Premium Rates (per month): N/A
10) Estimated Annual Aggregate Premium: N/A.
18. Special Limitations and Additional Information: N/A.

You have read the foregoing and understand and agree with the terms and conditions of the coverage as set
forth by Us and as reflected in the Application. You represent that You have formed Your Employee Benefit
Plan in compliance with all applicable state and federal laws. It is agreed that the statements in the
Application or in any materials submitted with this Application or attached to it, including all disclosure
information, are Your representations and shall be deemed material to acceptance of the risk by Us and that
the Policy is issued by Us in reliance on the truth and accuracy of such representations. Should subsequent
information become known which, if known prior to issuance of the Policy, would affect the premium rates,
factors, terms or conditions for coverage thereunder, We will have the right to revise the premium rates,
factors, terms or conditions as of the Effective Date, by providing written notice to You. Any fraudulent
statement will render the Policy null and void and claims, if any, will be forfeited.

THIS APPLICATION DOES NOT BIND COVERAGE. Upon approval of the Application, the Policy evidencing that

the coverage is in force will be issued by Us. Coverage will commence on the Effective Date set forth in the Policy.
This Application will attach to and form part of the Policy.

FRAUD WARNING: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, submits

an application for insurance or makes any claim for the proceeds of an insurance policy containing any false,
incomplete or misleading information may be guilty of insurance fraud.

AH-MSL-1001-NH (11-21) © QBE, 2021 Page 3 of 4