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Monthly Stop Loss Premium and
Enrollment Statement QBE

Reference

Policyholder Policy number Effective Date

City of Nashua LGS02732-22 July 01, 2022

TPA Report period and date

Anthem

Premium remitted: Report completed by:

O Net or O Gross

Payment details

Specific coverage Covered units Adjustments — Final units Rate Monthly cost
Composite 2050 x $75.46 =$

Total monthly Specific premium $
Total Premium $
Premium is due on the first of the month. The Policy is subject to cancellation without prior notice if premiums are received past the 31
day grace period.

Prior month adjustments are limited to the preceding three months. Please attach explanation to receive consideration for any
other prior months. Enrollment counts should include COBRA participants and retirees, if applicable. All premium and enrollment
questions should be directed to QBE at 1.800.742.9279.

Any acceptance by QBE of late payments shall not be deemed a waiver of its rights to terminate this Policy for any future failure of Policyholder to make
timely payments.

Payment instructions
Please make checks payable to QBE Insurance Corporation.

For payments made by regular mail:
QBE North America

P.O. Box 28034

New York, NY 10087-8034

For payments made by ACH/wire:

JPMorgan Chase NA

Routing # 021000021

SWIFT: CHASEUS33

Account # 339792571

Account Name: QBE Insurance Corporation Concentration Account

Please remit backup documentation at time of transfer to: Premium@qbeah.com

For overnight payments:

JPMorgan Chase NA

Attn: QBE Lockbox 28034

4 Chase Metrotech Center, 7" Floor East
Brooklyn, NY 11245

Section IV: Health, Safety & Environment

Our price includes having all our personnel properly trained pursuant to all state and federally mandated
OSHA and EPA standards and they will have the necessary PPE and be fully trained and qualified within
their respective trades, on the specific equipment they are working with, and the present and potential
hazards associated with the industrial environment in which we are working in. Our price does not include
the exposure of our personnel, to others or the environment to any previously applied coatings that
contain any hazardous materials, including, but not limited to, lead, asbestos or cadmium containing
compounds. If the presence of hazardous materials is unknown, we suggest samples of the existing
coatings should be taken to ascertain and evaluate the levels, if any, of hazardous substances to insure
compliance to all local, state and federal EPA and OSHA regulations. Our price includes all of our fieid
personnel receiving a safety briefing at your location, provided by others to acquaint our staff with the
specific health, safety and environmental considerations at the site, if necessary. Our pricing includes the
proper handling and disposal of all waste materials we generate on the project in customer provided
dumpster.

Section V: Quality Contral and Assurance

This project will be assigned a NACE or SSPC Certified Coating Inspector for quality control purposes. Our
corporate Quality Control (QC) programs are administered on an ongoing basis by a NACE or SSPC Level 3
Certified Coating Inspector. A site-specific inspection plan will be written and presented to you for your
consideration and approval prior to the commencement of our scope of work at your written request.

Section Vi: Schedule

Our pricing is based upon one mobilization to the site and continuing to proceed with our work on a full-
time basis, in one mobilization, until project is completed. We anticipate the project taking 7 calendar days
(weather permitting) in order to be in compliance to coating cure times and overcoat times.

Section Vil: Clarifications and Requiremenis

4. Our standard work hours are Monday thru Friday, 8:00 AM to 4:30 PM but hours may be adjusted

at the discretion of contractor to start as early as 6:00 AM and/or finish at sundown.

JB Safety International, Inc. ¢ P.O. Box 476 @ Seguin, TX 78156 ¢ 281-857-7919 éjeff@jbsafetyintl.com
htip:/Avww.jbsafetyinil.com

Page [5

For this project we may be working on Saturday and Sunday to apply coatings.

We require an area to store our material and equipment that is protected from the elements.

We will require sanitary restroom and break room facilities for our crew.

We will leave the site ina broom clean condition.

Our price does include the disposal of all of our generated waste materials in dumpsters provided

by owner.

7. Our price does not include repairing any damage to the installed coating system caused by the
neglect, abuse or accidents of others.

8. Our price does not provide for the cost of dehumidification and dust collection equipment, if
required.

9. Our price is based on customer providing any heat, lighting, water electricity or any other utilities.

2.
3.
4.
5.
6.

Section Vill: Insurance

We have various levels of insurance as mandated by local, state and federal laws for the various
jurisdictions we work in, including general liability, workmen’s compensation and automobile coverage. All
certificates of insurance will be presented prior to the commencement of our work to meet the minimum
project specifications and list additional insured parties, if required.

Section 1X: Pricing

We propose to furnish all of the labor, materials, lift, supervision and insurance necessary to complete the
project as defined and presented in this proposal for the lump sum of:

$ 11,000.00 { Eleven Thousand Dollars US}

Section X: Terms and Conditions

50% prior to mobilization, 50% on completion, 0.5%net 10
Our price does not include any local, state or federal
acceptance of a formal contract.

JB Safety International, Inc. @ P.O. Box 476 ¢ Seguin, TX 78156 ¢ 281-857-7919 ¢jeff@jbsafetyintl.com
htto:/Awww_jbsafetyintl.com

Page |6

Section Xi: Warranty

JB Safety Intentional, Inc. warrants that all of our installations shall be free from defects in workmanship
for a period of five (5) years after project completion. We expect the lifespan of the project to be
significantly longer. Materials have their own warranty.

Section XH: Acceptance

| have read and understand this proposal. The above prices, specifications and conditions are
satisfactory and | accept them. You are authorized to do the work as specified. Payment will be made as
outlined above.

Thank you for the opportunity to quote this to you. If you have any question, please call.

Sincerely,

Jeff Beard
President

JB Safety International, Inc. ¢ P.O. Box 476 @ Seguin, TX 78156 ¢ 281-857-7919 ejeff@jbsafetyintl.cam
htip-/Avww.jbsafetyintl.com

Page |?

PCO #006

Methuen Construction Co., Inc. Project: 181016 - Nashua Primary Tank Upgrades
144 Main Street - PO Box 986 2 Sawmill Road
Plaistow, New Hampshire 03865 Nashua, New Hampshire 03080

Phone: (603) 328-2222

Prime Contract Potential Change Order #006: Balancing Change Order

TO: City of Nashua FROM: Methuen Construction Ca., Inc.
229 Main Street 144 Main Street PO Box 980
Nashua New Hampshire, 03060 Plaistow New Hampshire, 03865

PCONUMBERIREVISION: 006/2 | CONTRACT: CS-330158-30 NASHUA PO 147380 - Nashua
Primary Tank Upgrades Prime Centract
Kelly Rochford (Methuen Construction Ca.,

REQUEST RECEIVED FROM: Joseph White (Methuen Construction Co., CREATED BY:

Inc.} Inc.)

STATUS: Pending - In Review CREATED DATE: 12/6/2019

scepuagge 00g . ee

cicib GUANGES OTT Gg EB RAND
CHANGE ORDER:

LOCATION:

“SCHEDULE IMPACT: - re "ACCOUNTING | AmountBased =
METHOD:

PAIDINFULL: | No - , TOTAL AMOUNT: $1,534.72 _ _ , ,

Methuen Construction (MC), hereby submits this PCO in accordance with the documentation referenced herein. It is expressly understood and agreed
that this proposal is valid for the time as specified within this document from ihe date of the PCO. The Proposal is based upon current day construction
costs and does not include escalation costs for any material items that are either volatile or market sensitive, This Proposal does not include overtime
acceleration or expediting costs. This proposal does not include the costs associated with out of sequence construction, interference, impact relaied
delays and disruptions. MC reserves its rights under the agreement to seek additional time, indirect and impact costs associated with the PCO, once the
impacts can be fully evaluated. This proposal is submitted based on the understanding that it is exempt from WBE/MBE participation requirements and
acceptance of this proposal waives the participation requiremenis associated with this additional work.

POTENTIAL CHANGE ORDER TITLE: Balancing Change Order
CHANGE REASON: No Change Reason

POTENTIAL CHANGE ORDER DESCRIPTION: (The Contract is Changed As Follows)

CE #11 - PCO 006 Balancing Change Order

Balancing change order to cover the markup loss in PCO #003 and #004. MCC was notified that the PCO markup structure was not acceptable.
Originally Methuen had been marking up jJabor 15% and materials 10%, when it should have been markup up 15% for both, Methuen has also been
marking up subcontractor costs at 5% in PCO #003 & #004 when it should have been 10%.

“REVISED 1/23/2020

This PCO reflects the markup loss in PCO's 3&4. This PCO also includes the $847.85 from PCO #3 which was not inciuded on CO#3. Change Order
#3 reflected a ($-650.00) in our overall contract, when it should have been a ($+847.85). This was noted and approved in an email discussion between
Anthony Crespo and Wiley Litile on 10/25/2019.

“REVISED 1/27/2020

ATTACHMENTS:
PCO 006 Balancing PCO#3&4, CO#3 Revision.pdi _PCO No 6- Balancing CO $160.06.pcf_

Burden Rate

# | Cost Code Description Type Amount (34.00% Applies te Labor) Subtetal

Methuen Construction Co., Inc. page 1 of 2 Printed On: 1/27/ 2020 11 :55 AM

PCO #006

(+) $669.00 relfects balancing
i oui the original (-} $660.00 Other $660.33 5 0.00 3660.33
deducted in CO #3
Value is from original POO #6
2 for the markup less on both Olher $ 160.06 5 0.00; $180.06
PCO 3&4
Value is from the approved
Az . .
3 PCO Wa Other 3 347,85 3 0.00) $847.85
Value is reflective of the
4 difference from original and Other ($733.52} 30.00 ($133.52)
revised PCO #004
Subtotal: $1,534.72 $0.00 $1,534.72
GC Work Total Fee - Labor: 15.00% Applies to Labor and Burden, $0.60
GE Work Total Fee - Items 2, 3, 4: 0.00% Apnlics ta Other, Materia, and Equipment. $6.00
GC Subcontractors Work Fac: 5.00% Applies to Subcontractor. $0.00
Bond & General Liability: 6.00% Applies to Other, Matertal, Committed Costs, Labor, Rental Equipment Relief, Equipment, Subcontractor, and Burden. $0.00
Srand Total: $1,534.72
Dave Cockburn (Wright-Pierce} Gity of Nashua Methuen Construction Co., Inc.
14 Bowdoin Mill Island 229 Main Street 144 Main Street PO Box 980
Topsham, Maine 04086 Nashua, New Hampshire 03060 Plaistow, New Hampshire 03865
SIGNATURE DATE SIGNATURE DATE SIGNATURE DATE
Methuen Construction Co., Inc. page 2 af 2 Printed On: 1/27/2020 11:55 AM

Doc #: 06
Ref. Document: 184016-PCO#6
PROJECT NAME: Date: 22-Jan-20
Nashua Primary Tank Upgrades
PROJECT NO: 181016
PHASE
COST SUMMARY SHEET
Balancing PCO, PCO#8 not reflected on CO#3
A NiC Labor (Recap Sheet):
B MC Materials, & Equipment (Recap Sheet):
Cc WIC Fee (A x 15%) + (B x 10%):
D Subtotal MC Work (A+B +C):
E Total Subcontractors (Below):
F MC Mark-up on Subcontractor Work (5%):
G Bond (1%) and General Liability (1%): $0.00
Total Proposal(D+E+F+G): $ 4,534.72
METHUEN CONSTRUCTION SUMMARY
METHUEN CONSTRUCTION Description Amount
This (+}$660.00, reflects balancing out the
$660.33 original (-)$660.00 deducted in CO#3 $ 660.35
This vaiue is from the original PCO#6 for
$160.06 the markup loss on both PCO384 =| S 160.06
$847.85 This value us from the approved PCO #3 $ 847.85
This value is reflective of the difference
“$133.52 from the original and revised PCO-004. «| © (133.52)
5 “
5 -
3 -
Totak $ 1,534.72

Balancing PCO, Credit Request missed on CO#3

Scope: This PCO reflects the markup loss in PCO's 3&4. This PCO also includes the $847.85 from PCO#3 which was not included on CO#3. Change Order #3
reflected a (-660.00) in our overall contract, when it should have been a (+847.85). This was noted end approved in an email discussion between Anthony Crespo &

Wiley Little 10/25/2079

FRONT END LOADER

ROAD SAW

BREAKER

FORKLIFT LULL
1

RE DRILL

SUBTOTAL

$0.00

-00

$66.40 .
$54.42 50.

535.88
$45.54 50.

$30.04
$15.08

$120.00

1-LABOR
CATEGORY HRS RATE/HR PREMIUM SUBTOTAL LINE TOTAL TOTAL
00 $0.00
FOR
LABORER
50.00
PLUMBER
$0.00
MILL
$0.00
-00
SUBTOTAL
2-MATERIALS
DESCRIPTION QTy UNIT UNIT COST SUBTOTAL
Estimated
Consumables $ §00.00 § 500.00 $ -
Dumpster / Disposal $ 750.00 § 750.00 $ “
SUBTOTAL 3 -
i3-EQUIPMENT
CATEGORY HRS RATE UNIT SUBTOTAL
iEXCAVATOR PC300 $180.35 HR $0.00
!EXCAVATOR CAT 330 $100.37 HR $0.00
iEXCAVATOR CAT 320 i $5871 HR $0.00
BUMP TRUCK i $61.23 HR

Pape 2 of 3

1/24/2020 - 4:02 PM

Balancing PCO, Credit Request missed on CO#3

Scope: This PCO reflects the markup loss in PCO's 384, This PCO also includes the $847.85 from PCO#3 which was not included on CO#3. Change Order #3
teflected a (-860,00) in our overail contract, when it should have been a (+847.85). This was noted and approved in an email discussion between Anthony Crespo &
Wiley Litlle 10/25/2049

4-SUPPLEMENTAL COSTS

DESCRIPTION QTy RATE UNIT SUBTOTAL

T DRAWINGS

ITRAVEL

ORAGE
E& WA

PHONE

SUBTOTAL $0.00
(5-BURDEN
CATEGORY RATE
BURDEN RATE 34.00% $0.00
6-SC WORK TOTAL
SUBTOTAL (Item 1+2+3+4)
7-SUBCONTRACTORS WORK
SUBCONTRACTOR UNIT COST Qty COST TOTAL
SUBTOTAL $0.00
8-FEE
GC (15% X ems 145 + 10% X items 26384 + 5% X item 7)
|38-SUBTOTAL

BOND (1% X ftema)
GENERAL LIABILITY (1% X item 8)

9-TOTAL (item 8 + Bond + General Liability)

Page 3 of 3 1/24/2620 - 4:02 PM

CITY OF NASHBA, NH
PRIMARY LAKR UPGRADES

CHANGE ORDER XO. 3
SUMMARY

GRIGINAL CONTRACT PRICE: PATE OF SUBSTANTIAL COMPLETION

4 F908 ele aie
CONTRACE PRICE TIME PRIQH TOCHANGE ORDER 3 SASL] GR2GN
ri. ies of Audi Deda
POODE ROO Na 3 Cont Re. geet for flrs ing Piura Water Purp ianet feeder 3 ee o dnt
POG POO Nat MCC 2Sgied Suna 5 S344 Tt ots
det Contract Price fnereses of this Change Onder (PCO-47; § Faas ta 4 ane
CONTRACT PRICE? TIME WITH ALL APDROVED S HAGE ORDERS: MASTS ES eleqara

Value should be
$4,010.59 based off the
updated PCO No 4. That
is reflected in this PCO.

'GO'LPE Sq P|NOYS SNIEA SIL} JEU] BJOU SSEdIqj

Please note that this value should be 847.85,