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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 Policyholder: 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) icity) (state) (zip)

Contact Person: Kim Kleiner Email: kleinerki@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 Endorsernent AH-MSL-5013
Expedited Reimbursement Endorsement AH-MSL-5011-NH
New Hampshire Endorsement AH-MSL-5010-NH
Rate Stabilization Endorsement AH-MSL-5005

NIA

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 03101

Your broker/agent of record:

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

AH-MSL-1004-NH (11-27) © QBE. 2021 Page 1 of 4

Board of Aldermen Page 11
September 27, 2016

in terms of the work force. | am on the Board of the Huntington as well so | hear about their challenges
and what it means. We have a great struggle in bringing in people who can meet the needs of our
patients and we’ve had a great history in our organization of educating people who are coming up
through the ranks and being very productive. There is a family, the Lopez-Grasper Family, and | employ
eleven of those individuals. They are from Boliva and they have started out many of them as nurse’s
aides and in other roles and have risen up to the ranks of nursing and into leadership roles because of
their industrious efforts. | know when | walk on a unit and | see one of them | feel good, my A team is
there. | can tell you many stories about individuals who have come to our community and made a huge
difference in expanded access to services here. | hope you will vote wisely and support the resolution
that the Mayor has put forth.

Mr. Dan Weeks, 7 Shattuck Street

| am a proud 12™ generation granite stater but even more proud to be married to a brand new U.S.
citizen, my wife, who emigrated here from South Africa. She is a Ph.D., a human rights lawyer and an
academic and she is glad to be offering her skills to our communities. We recently bought a home in a
neighborhood that was named after immigrants, French Hill. According to recent studies, immigrants in
New Hampshire, not only counter the rapid aging of our population and out migration of our youth but
they also make incredible contributions to our tax base and to the well-being of our communities. The
National Academy released a landmark study on the effects of immigration in this country and found here
in New Hampshire that immigrants contribute 3X in tax revenue more than they receive in public benefits.
My wife and | found that Nashua is the most diverse city in New Hampshire and that is why we decided
to buy a home here and raise our two kids here and we are glad that we did. Even though politics are in
just about everything these things, | understand that, but it’s my view that we are already a Welcoming
City and we can do no wrong and only do good by affirming that publicly and making a statement to the
rest of the state joining Manchester and Concord and following the encouragement of our own Chamber
of Commerce and the United Way and the ACLU and St. Joseph’s Hospital and others to publicly affirm
what we already are and ought to be more and more; a Welcoming City.

PETITIONS — None
NOMINATIONS, APPOINTMENTS AND ELECTIONS — None

REPORTS OF COMMITTEE

Budget Review Committee .............. cece cccceeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeees 09/20/16

There being no objection, President McCarthy declared the report of the September 20, 2016
Budget Review Committee accepted and placed on file.

Finance Committee ..0......... cece cece eeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeees 09/21/16
There being no objection, President McCarthy declared the report of the September 21, 2016
Finance Committee accepted and placed on file.

Committee on Infrastructure ....0... ccc ccecccecccececececececesecseceeectereverseeaters 09/19/16

There being no objection, President McCarthy declared the report of the September 19, 2016
Committee on Infrastructure accepted and placed on file.

Human Affairs Committee 20.0... cc cecceccceecceceeeceeeceseeeeaeeeaeereeereeeaees 09/12/16

There being no objection, President McCarthy declared the report of the September 12, 2016
Human Affairs Committee accepted and placed on file.

In WITNESS WHEREOF, the parties hereto have caused this contract to be signed and intend to be
legally bound thereby.

dE

City of Nashua, NH (signature) iParametrics, LLC (signature)
James W. Donchess, Mayor Jeffrey Stevens, Vice President
(Printed Name and Title) (Printed Name and Title)
3.7,2022
Date Date

AG 4of4

12. YourPPO Network is: Blue Cross Blue Shield
13. Your Utilization Review Provider is: Anthem

14. Eligible for coverage:

Retirees: Yes [X] No[ ] Late Entrants: Yes [ ] No [X] Other - Retirees Pre-65 Only: Yes[X]No[ ]
15. Estimated Covered Units:

Covered Unit Description Units

Composite 2050

16, Initial premium deposit accompanying this Application:
$154,693.00

17. COVERAGES

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
NIA

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 and
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.
B. 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

AH-MSL-1001-NH (11-21) © QBE, 2021 Page 2o0f 4

3) Estimated Annual Aggregate Attachment Point: N/A
‘A. For Total Covered Units under 51 employees. amount entered cannot be less than the 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: WA
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) G OBE. 2021 Page 3 of 4

ACCEPTED BY THE POLICYHOLDER:

Signed at

Date ©

ACCEPTED BY THE COMPANY:

Signed at Marblehead, Massachusetts

Date

AH-MSL-1001-NH (11-21)

Policyholder (correct legal name)

By (Officer's signature and title)

(Print Name)

Signature Broker/Agent of Record

(Print Name)

On behalf of the Company

Tara Krauss, Head of A&H

By (Officer's name and title)

) QBE, 2021

Page 4 of 4

Monthly Stop Loss Premium and
Enrollment Statement QBE

Reference

Policyholder Policy number Effective Date

City of Nashua LGS$02732-22 July 01, 2022

TPA Report period and date

Anthem

Premium remitted Report completed dy.

O Net or O Gross

Payment details

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

Total monthly Specific premium $
Total Premium = $
Premium is due on the first of lhe 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 de directed to QBE at 1.800.742.9279.

Any acceptance by O8€ of tate payments shail nol be deemed a waiver of rts nghts fo terminate this Pusicy for any future faiture 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

Jim Donchess

Mayor e City of Nashua
To: Board of Aldermen
From: Mayor Jim Donchess
Date: June 29, 2022
Re: Multi-Year Contract Award — Financial Auditing Services

Pursuant to NRO: § 5-74/B: A contract that extends from the current fiscal year into succeeding
fiscal year(s) in which no funds have been appropriated nor otherwise designated for this purpose
shall be approved by the full Board of Aldermen before the contract shall become binding on the
City.

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: General Financial Statement Auditing, Federal Single Audit and
Schedules for FY2022 & FY2023
Value: $132,500 per year for 2 years to total $265,000
Vendor: Melanson
Purchasing Memo#: 23-305 dated June 29, 2022
Contract Term: 2 years
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

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

June 29, 2022
Memo #23-305

TO: Mayor Donchess
Finance Committee

SUBJECT: Financial Audit Services in the amount not to exceed $265,000 funded from 53114
Accounting & Auditing Services/General Fund $193,000/ Solid Waste Fund $29,000/
Wastewater Fund 543,000

Please see attached communications from John Griffin, Chief Financial Officer, dated June 23, 2022 for
project specific details related to this purchase. Below please find a summary of the purchase approval
request:

Item: General Financial Statement Auditing, Federal Single Audit and Schedules for
FY2022 & FY2023

Value: $132,500 per year for 2 years to total $265,000

Vendor: Melanson

Department: 126 Financial Services
Source Fund: 53114 Accounting & Auditing Services/General Fund $193,000/ Solid Waste Fund
$29,000/ Wastewater Fund $43,000

Ordinance: Pursuant to NRO § 5-83 Professional Services (A) In the purchase of accounting,
architectural, auditing, engineering, legal, medical and ambulance services and
purchases of independent professional consultant services for personnel, data
processing, actuarial, planning, management and other comparable purchases
competitive bidding shall not be required.

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

Regards,

Kelly Parkinson
Purchasing Manager

Cc: J Griffin
J Graziano

THE CITY OF NASHUA the Ge Gy

Financial Services Division

Office of the Chief Financial Officer

TO: Mayor James Donchess

FROM: John L. Griffin and Rosemarie Evans

DATE: June 23, 2022

RE: Recommendation to Extend Melanson Contract

The purpose of this communication is to recommend extending the existing
contract with Melanson for services to audit the City’s general-purpose financial
statements, Federal Single Audit and schedules for the fiscal years F¥2022 and
FY2023. The contract amount is $132,500 for each of the FY2022 and FY2023
audits.

During the past several years, this firm has provided audit services for the City’s Lawson
and MUNIS Financial Systems including General Ledger, Payroll, Accounts Receivable,
Accounts Payable, Procurement, Cash Receipts and Fixed Assets.

In summary, given the institutional knowledge of the City’s financial systems and
internal controls, it is important to maintain the services from the incumbent external
auditor — Melanson for continuity purposes.

229 Main Street * Nashua, New Hampshire 03060 * Phone (603) 589-3173 + Fax (603)
589-3168