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SCHEDULE OF INSURANCE

Schedule of Insurance

The Schedule(s) of Insurance for Group Insurance Policy GL-207759 listed below:
e = Basic Life Insurance

e Accidental Death, Dismemberment and Loss of Sight Benefit

e Supplemental Life Insurance

are shown in Booklet-certificate(s) 207759(GL)4.17, 207759(GL)5.12, 207759(GL)6.5, 207759(GL)7.3,
20775HGL)8.3, 207759(GL)9.3, 207759(GL)10.4, 207759(GL)11.3, 207759(GL)12.3, 207759(GL)13.3,
207759(GL) 14.3, 207759(GL)15.3, 207759 GL)16.3, 207759(GL)17.3, 207759(GL) 18.3, 207759(GL)19.3,
207759(GL)20.2, 207759(GL)21.3, 207759(GL)22.2, 207759(GL)23.2, 207759(GL)24.2 and 207759(GL)1.18.

The Schedule(s) of Insurance will control the:
e benefit amounts and maximum limits;

e eligibility and effective date rules; and

e other schedule amounts and limits,

which apply to the employees of the Policyholder.

GR-11383-HLA(G3.1) PI-3.21

PREMIUMS

Initial Monthly Premium Rates

The initial monthly premium rates to be charged for employee Coverage and/or child/spouse coverage, if applicable,

will be:

Basic Life Insurance $.113 for each $1,000 of Group Life Insurance

Supplemental Life Insurance

$ for each $1,000 of Supplemental Life Insurance
the monthly premium rate shall be determined in
accordance with the Insured Person’s Age as follows:

Employee Age Rate
Less than 30 $.065
30-35 $.07
35-40 $.082
40-45 $.135
45-50 $.165
50-55 $.386
55-60 $.61
60-65 $.937
65-70 $1.436
70-75 $3.007
75 or over $4.192

Accidental Death, Dismemberment
And Loss of Sight Insurance

The Initial Monthly Premium Rates may be converted as follows:

To Convert Rates to: Use a Conversion Factor of:
-- annual rates 11.8227

-- semi-annual rates 5.9557

-- quarterly rates 2.9852

$.03 for each $1,000 of Maximum Benefit

GR-11383-HLA(4)

PI-4.04

PREMIUMS
(Continued)

Change in Monthly Premium Rates
Initial Monthly Premium rates are guaranteed as follows:

Basic Life Insurance until 36 months
Supplemental Life Insurance until 36 months
Accidental Death, Dismemberment, and Loss of Sight Insurance until 36 months

Subject to the Rate Guarantee period shown above, Hartford Life has the right to change premium rates on any
premium due date if:

e written notice is delivered to the Policyholder's last address on record; and

* the change is effective at least 31 days after the date of notice.

The rate guarantee described above (the "Rate Guarantee") supersedes only those provisions appearing elsewhere in
this policy which give Hartford Life the right to change the premium rates, and then, only for the period of time stated
for the Rate Guarantee. However, Hartford Life may change the premium rates during the Rate Guarantee period if
there is a change in the group policy, or if there is a 10% increase or decrease in the number of insured employees, or
if the Policyholder adds or deletes a subsidiary or affiliated business entity. Hartford Life may also change the
premium rates during the Guarantee Period if there has been a material misstatement in the reported experience during
the pre-sale process. The Rate Guarantee in no way affects, amends or supersedes any other provision in this policy.

Calculation
Premiums may be calculated by multiplying the rate times the applicable number of units of coverage.

If any insurance is added, increased or becomes effective after the policy is in force, the premium charges will begin:
e the day the coverage is effective, if it is also the first day of a policy month; or if not
e the first day of the next policy month.

For insurance which is terminated, premium charges will stop as of the first day of the next policy month.

Premiums may be calculated by any other method which both Hartford Life and the Policyholder agree to in writing.

GR-11383-HLA(5) PL-5.17

PREMIUMS
(Continued)

Premium Payments
Premium payments are due and payable in full to a place designated by Hartford Life or, with respect to the initial
premium payment, premium payments may be made to an authorized agent of Hartford Life.

Payment of premiums for a period before it is due will not guarantee the insurance for that period.

Experience Rating

If the policy is experience rated, any credit amount due the Policyholder will be allowed him on the Policy
Anniversary Date and, at the Policyholder's request, will be:

e paid to him in cash;

e used to reduce his premiums; or

e used to provide additional insurance for Covered Persons.

Any credit amount shall be determined by the rating plan or plans used by Hartford Life.

GR-11383-HLA(6) PI-6.00

POLICY PROVISIONS

Entire Contract

The contract between the parties consists of:

e the policy;

© the application of the Policyholder, a copy of which is attached to and made a part of the policy when issued; and
e the applications, if any, of each insured person.

All statements made by the Policyholder, Participant Employers, and persons insured under the policy are true and
complete to the best of the knowledge and belief of the person(s) making them. No statement will be used in any
contest unless it is in writing and a copy of it is given to the person who made it, or to his beneficiary.

Incontestability
Except for non-payment of premium, the insurance provided by the policy cannot be contested after such insurance
has been in effect for a period of 2 years.

Change in The Policy

No change may be made unless approved in writing by the President; or a Vice President; an Assistant Vice President;
a Secretary; or an Assistant Secretary of Hartford Life. No other person may change or waive any part of the policy.
Any approved change shall be added to the policy in writing.

If any change to state or federal law, including but not limited to the Federal Social Security Act, affects Hartford
Life's liability under the policy, Hartford Life may change the policy, the premiums or both. Such change:

« will be effective as of the date of the change to the state or federal law;

e will not be made until Hartford Life gives the Policyholder 31 days notice.

Right to Amend

Notwithstanding the above, after the policy has been in force for 12 months, Hartford Life may change any or all of
the provisions of this contract by notifying the Policyholder. Hartford Life must give the Policyholder at least 31 days
advance written notice of any change.

Grace Period

Hartford Life will allow the Policyholder a 31 day grace period for the payment of all premiums after the first. During
this 31 day period, the policy will stay in force. If the owed premium is not paid by the 31st day, the policy will
automatically terminate. If the Policyholder gives Hartford Life written advance notice of an earlier cancellation date,
the policy will terminate on the earlier date. Premium is due for each day the policy is in force.

GR-11383-HLA(7) PI-7.21

POLICY PROVISIONS
(Continued)

Termination of Policy
Hartford Life may terminate the policy for the following reasons by giving the Policyholder 45 days written notice:
e The Policyholder fails to furnish any information which Hartford Life may reasonably require;
The Policyholder fails to perform any of his other obligations pertaining to this policy;
Less than 100% of the persons eligible for coverage on a Non-contributory Basis are insured; or
Less than 75% of the persons eligible for coverage on a Contributory Basis are insured.
Fewer than 10 persons are insured.

In addition, Hartford Life may terminate this policy on any premium due date after the policy has been in force for 12
months.

Certificate
Hartford Life will give the Policyholder an individual Booklet-certificate for each insured employee. The Booklet-
certificate is part of the policy, and will explain the important features of the policy.

Data To Be Furnished

The Policyholder will give Hartford Life all information Hartford Life needs regarding matters pertaining to the
insurance. At any reasonable time while the policy is in force and for | year after that, Hartford Life may inspect any
of the Policyholder's documents, books, or records which may affect the insurance or premiums of this policy.

If the Policyholder gives Hartford Life any incorrect information, the relevant facts will be determined to establish if
insurance is in effect and in what amount.

No person will be deprived of insurance to which he is otherwise entitled or have insurance to which he is not entitled,
because of any misstatement of fact by the Policyholder. Any required adjustment may be made in premiums or
benefits.

No Replacement for Workers' Compensation
The policy does not replace Workers’ Compensation or affect any requirement for Workers' Compensation coverage.

Time Period
All periods begin and end at 12:01 A.M., standard time, at the Policyholder's address.

Jurisdiction
This policy is governed by the laws of the state where it is delivered.

GR-11383-HLA(8) PL-8.00

Prepare. Protect. Prevail?” (

THE molec
HARTFORD

Business Insurance
Employee Benefits
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March 10, 2016

Tom De Lacey

Workplace Benefit Solutions/HUB International New England
1667 Elm Street, Suite 3

Manchester, NH 03101

Re: July 1, 2017 Group Benefits Renewal Information for City of Nashua, New Hampshire
Dear Tom:

We appreciate the opportunity to be your partner in delivering group benefits from The Hartford’
to City of Nashua, New Hampshire and their employees. We look forward to renewing their
Life benefits at this time and continuing our partnership for many years to come.

The attached letter contains renewal information for you to share with your client. It is very
important that you deliver the attached information to City of Nashua, New Hampshire

in order to ensure that we can provide timely and accurate service to your client. Please
note — this renewal information has not been sent to your client.

| look forward to continuing this valuable partnership with you, and delivering on promises every
day. | am happy to answer any questions you may have, so please contact me anytime.

Sincerely,

Paul Bogdanovich
Account Executive, Group Benefits
The Hartford

The Hartford® is The Hartford Financial Services Group, Inc. and its subsidiaries including issuing companies Hartford Life Insurance
Company, Hartford Life and Accident Insurance Company and Hartford Fire Insurance Company. Administrative services are provided by the
Hartford-Comprehensive Employee Benefit Service Company. In Ml, NH, NM, NC, and WY, administrative services are provided by Hartford
Life and Accident Insurance Company. Home Office is Hartford, CT. Renewals 2015.

Prepare. Protect. Prevail:

THE sos
HARTFORD

Business Insurance
Employee Benefits
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March 10, 2016

Larry Budreau

City of Nashua, New Hampshire
229 Main Street

Nashua, NH 03061-2019

Re: July 1, 2017 Renewal Information for Your Group Benefits with The Hartford
Dear Larry Budreau:

Thank you for giving The Hartford the opportunity to provide benefits to the employees of City of
Nashua, New Hampshire. The Hartford is committed to enhancing your employees’ financial
security and helping you provide attractive benefits. We look forward to renewing the Life and
Disability benefits at this time and continuing our relationship for many years to come.

To determine the renewal rate, The Hartford analyzes a variety of factors to ensure that you
receive excellent benefits and valuable service at a competitive and affordable price. A careful
review is conducted of your demographic information, industry classifications, experience
results, and overall benefit package.

We have completed a comprehensive review of your benefit plan in order to determine the
appropriate funding level for the upcoming new policy period, beginning July 1, 2017. The chart
below summarizes the detailed renewal rate information. These renewal rates require that all
coverage lines are renewed as a package.

Coverage and Volume Current Rate * Current Renewal Rate * Renewal Monthly Rate
Policy Number Monthly as of 01/01/2017 Monthly Premium Guaranteed
Premium Premium Change Until
Basic Life - 207759G 113,337,500 | $0.15 per 1000 $ 17,000.62 | No Change NoChange | $0 07/01/2019
Basic ADD - 2077596 113,337,500 | $0.03 per 1000 $ 3,400.13 | No Change No Change | $0 07/01/2019
Supplemental AD&D 46,258,000 $ 0.035 per 1000 $1,619.03 | No Change NoChange | $0 07/01/2019

The Hartford® is The Hartford Financial Services Group, Inc. and its subsidiaries including issuing companies Hartford Life Insurance
Company, Hartford Life and Accident Insurance Company and Hartford Fire Insurance Company. Administrative services are provided by the
Hartford-Comprehensive Employee Benefit Service Company. In MI, NH, NM, NC, and WY, administrative services are provided by Hartford
Life and Accident Insurance Company. Home Office is Hartford, CT. Renewals 2015.

Prepare. Protect. Prevail!

Supplemental life - Renewal Rate Rate
207759 as of 01/01/2017 Guaranteed
Until
SUPP LIFE < 30 $ 0.0580 per 1000 | 07/01/2019
SUPP LIFE 30 - 34 $ 0.0630 per 1000 | 07/01/2019
SUPP LIFE 35 - 39 $ 0.0730 per 1000 | 07/01/2019
SUPP LIFE 40 - 44 $ 0.1210 per 1000 | 07/01/2019
SUPP LIFE 45 - 49 $ 0.1480 per 1000 | 07/01/2019
SUPP LIFE 50 - 54 $ 0.3470 per 1000 | 07/01/2019
SUPP LIFE 55 - 59 $ 0.5490 per 1000 | 07/01/2019
SUPP LIFE 60 - 64 $ 0.8430 per 1000 | 07/01/2019
SUPP LIFE 65 - 69 $ 1.2920 per 1000 | 07/01/2019
SUPP LIFE 70 - 74 $ 2.7060 per 1000 | 07/01/2019
SUPP LIFE 75 - AND $ 3.7720 per 1000 | 07/01/2019

OVER

THE

HARTFORD
Business Insurance
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* For policies that are list-billed by The Hartford, premium and volumes are based on the most recent list bill. For policies that are self-

administered, premiums and volumes are based on the most recent census information that we have on file.

The Hartford® is The Hartford Financial Services Group, Inc. and its subsidiaries including issuing companies Hartford Life Insurance
Company, Hartford Life and Accident Insurance Company and Hartford Fire Insurance Company. Administrative services are provided by the
Hartford-Comprehensive Employee Benefit Service Company. In MI, NH, NM, NC, and WY, administrative services are provided by Hartford

Life and Accident Insurance Company. Home Office is Hartford, CT. Renewals 2015.

Prepare, Protect. Prevail

THE
HARTFORD

Business Insurance
Employee Benefits
Auto

Home

Doing business with The Hartford is about much more than price. We deliver on our promises
every day through product features and responsive service targeted to you and your employees’
unique needs.

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a unique URL or cistributed by an ernail blast to ernpiovees, My7T romorrow® can be accessed
securely from home as weil as work. This friendly, online environment can heip clarify what the
beneilis you are pro ng cover, address the affordabil ity of these producis and some commen
misconceptions, coffe 2m access to your company’s plan details and enrol iment farm/site, and
more. Income protection can be a complex issue. But with MyT omorrow®, your employees will have
@ convenieni tool to help them make good decisions.

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Additional Services for Employees

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Services include:

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¢ Beneficiary Assist® Counseling Services’ "(Life and Accident) Compassionate expertise to
help employees or their loved ones cope with emotional, financial and legal issues that arise
after a loss. Includes unlimited phone contact with professionals, as well as five face-to-face
sessions.

¢ Travel Assistance & ID Theft Protection Services. ?(Life, Accident & Long-term Disability)
Services include pre-trip information that helps employees feel safe and secure while traveling. It

' EstateGuidance, Ability Assist® and Beneficiary Assist are offered through The Hartford by ComPsych®. ComPsych is not affiliated with The
Hartford and is not a provider of insurance services. The Hartford is not responsible and assumes no liability for the services provided by
ComPsych and reserves the right to discontinue these services at any time. EstateGuidance and ComPsych are registered trademarks of
ComPsych Corporation,

? Travel Assistance and ID Theft Protection Services are provided by Europ Assistance USA. Europ Assistance USA is not affiliated with The
Hartford and is not a provider of Insurance services. Europ Assistance USA may modify or terminate all or any part of this service at any time
without notice. The Hartford is not responsible and assumes no liability for the services provided and reserves the right to discontinue these
services at any time.

The Hartford® is The Hartford Financial Services Group, Inc. and its subsidiaries including issuing companies Hartford Life Insurance
Company, Hartford Life and Accident Insurance Company and Hartford Fire Insurance Company. Administrative services are provided by the
Hartford-Comprehensive Employee Benefit Service Company. In MI, NH, NM, NC, and WY, administrative services are provided by Hartford
Life and Accident Insurance Company. Home Office is Hartford, CT. Renewals 2015.