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10.

Purchaser:

FORM# PS_AO1

Purchaser fails to pay within fifteen (15) days of the due date, Within
thirty (30) days after the run-out period ends, HPHC will return the
remainder of the balance of the Plan Working Deposit to Purchaser.
HPHC will subsequently request instruction from Purchaser as to
how future additional payable claims, if any, should be paid. Due to
the nature of the data on which the Massachusetts Uncompensated
Care Pool surcharge amounts are calculated, the final billing for this
charge will take place following the end of the run out period.
Similarly, the final billing for charges incurred under the New York
Health Care Reform Act will occur following the run out period.

Excluded Expenses and Services. Expenses incurred by the Plan, or by
HPHC on behalf of the Plan, for the following services shall be the sole responsibility of

(a)

(b)

(c)

(e)

(f)

(g)

All direct and indirect costs for the providers and suppliers in
connection with the delivery of health care services and supplies to
Members, including all compensation and reimbursement paid to
medical and paramedical personnel and health care facilities;

All insurance costs, including professional liability/malpractice,
general liability and all reinsurance and stop-loss, which may be
purchased for Purchaser or the Plan;

Taxes or other governmental obligations of the Plan or Purchaser,
including without limitation, surcharges assessed on paymenis to
health care providers for the funding of uncompensated care pools
or similar arrangements.

Purchaser’s annual corporate financial audit, and such other audits
and financial statements required by state or federal law and costs
associated with preparation of Purchaser’s corporate tax returns.

Costs of legal services for the Plan which arise in the normal course
of the Plan’s operations, including HPHC’s provision of services for
the Plan, except as otherwise provided in section 1.13 of the
Purchaser Service Agreement.

Filing fees and penalties and other fees associated with annual and
other reports required by federal and state statutes and regulations
applicable to the Plan; and

f&xpenses for independent legal, independent accounting and
independent actuarial services of Purchaser or the Plan.

05/17/2002

©P9 Harvard Pilerim
iy HealthCare’

Tlarvard Pilurim Wealth Care includes Harvard Pilgrim Health Care,
Harvard Pilgrio Health Care of Connecticut, Harvard Pilgrim
Tealth Care of New England and HPIIC Insurance Company.

RATE PROPOSAL

Company Name: City of Nashua
Group Number: 027219

Effective Date: 07/01/2016 - 06/30/2017
Plan ID :MD0000014789/RX0000011897
Product: NH HMO-Best Buy Plan Year Stand Alone Option

-T
Subtotal: Admin & Reinsurance

CAR Total (Claims & Admin &

PURCHASED OPTION * FEES

Fitness Club Reimbursement Program $0.00 PEPM Flat Fee
Fitness Reimbursement Max $150.00 PSPCY Level
BENEFITS SUMMARY (Refer to the Schedule of Benefits for benefit details)
Office Visit $20

Emergency Room $100

Inpatient Services DED

Day Surgery DED

Coinsurance In-Network None

Coinsurance Out of Network NA

Deductible In-Network Individual $250 PPY

Deductible Out of Network Individual NA

Deductible In-Network Family $500 PPY

Deductible Out of Network Family NA

Gut of Pocket Maximum In-Network Individual $6,450 PPY

Out of Pocket Maximum Out of Network Individual | NA

Out of Pocket Maximum In-Network Family $12,900 PPY

Out of Pocket Maximum Out of Network Family NA

Chiropractic Care 12 visits PPY

Rx Copay 30 Days $5/$15/$35/NA/NA
Rx Copay Mail Order $5/$30/$70/NA/NA
Cross Accumulation Cross Accumulated
Rx Copay Deductible N/A

OOP Max Individual Rx $6450

OOP Max Family Rx $12900

Formulary Premium

* In the event that you purchase or have purchased a specialty care and disease management program, please note that specialty care and
disease management program Service Fees must be paid for minimum onc-year periods and no retroactive termination of members is permitted.

*Deductibles and Out of Pocket Maximums are Per Calendar Year (PCY) unless otherwise indicated to be Per Plan Year (PPY)

Max OOP=Maximum Out of Pocket, Chiro=Chiropractic Rider, Rx=Prescription, PCY=Per Calendar Year, OV=Office Visit, IN=In Network,
OON=Out of Network, ER=Emergency Room, PMPM=Per Member Per Month, PEPM=Per Employee Per Month, PDMPM=Per Diseased
Member Per Month, PSPC Y=Per Subscriber Per Calendar Year

Form No. 1207 Printed Date: 03/29/16

] Harvard Pilgrim Harvard Pilgrim Health Care includes Harvard Pilgrim Llealth Care,

’ HealthCare Hath Care of ow Engin nd HE mete Cpe

RATE PROPOSAL
Company Name: City of Nashua Effective Date: 07/01/2016 - 06/30/2017
Group Number: 027219 Plan ID : MD0000014789/RX0000011897
Product: NH HMO-Best Buy Plan Year Stand Alone Option

Rate Proposal terms and conditions

lf applicable, please review the detailed caveats page(s) released by the Stop-loss Carrier.
Preferred Drug List Rebates - Harvard Pilgrim Health Care will retain 30% of any net preferred
drug list rebate recovery attributable to prescription drug products utilized by participants.

3. The customer will retain 70% of that rebate recovery amount.

These figures are approximate based upon 315 subscribers.

5. You may request a fully insured quote, which could provide greater savings (e.g., reduced
HIPAA compliance, avoidance of stop loss volatility and enhanced discounts reflected in fully
insured rates).

Noo

-

Tam authorizing Harvard Pilgrim Health Care (including its affiliates) to proceed with the account setup of the benefit package and fees in this rate proposal,
which is subject to the execution of Harvard Pilgrim's Administrative Service Agreement (ASA) or an applicable amendment to the ASA.

Signature of Company Official/Broker/Consultant Title Date
Form No.1207 Printed Date: 03/29/16

rg4 :
HE

HARTFORD

AMENDMENT TO GROUP POLICY GL-207759 PROCESSED ON FEBRUARY 24, 2015. ANY CHANGES

BETWEEN THIS POLICY AND THE PREVIOUSLY ISSUED POLICY ARE EFFECTIVE FEBRUARY 1,
2015. ALL OTHER TERMS, CONDITIONS AND DATES REMAIN UNCHANGED.

Name of Policyholder: CITY OF NASHUA, NEW HAMPSHIRE

Policy Number: Effective Date: Place of Delivery:
GL-207759 January 1, 1997 New Hampshire
Anniversary Dates: Premium Due Dates:

January 1 of each year, beginning in 2016. Monthly, on the first day of each policy month.

HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY
200 Hopmeadow Street, Simsbury, Connecticut 06089

(A stock insurance company, herein called Hartford Life)

Agrees with the Policyholder to insure certain persons who are entitled to the insurance provided by this policy. This
policy is issued in consideration of the application of the Policyholder, and the payment of the first premium. The
first premium is due and payable on the effective date of the policy. Subject to the policy's grace period provision, all
premiums after the first must be paid when or before they are due.

Signed for Hartford Life:
/. wtgtinominn fell et a 5 : + 4 tl trench
Terence Shields, Secretary Michael Concannon, Executive Vice President

Table of Contents
Agreement to Insure
Participant Employers
Incorporation Provision
Schedule of Insurance 3
Premiums
Policy Provisions

NY BeE WP Re

GR-11383-HLA(1) PI-1.00

PARTICIPANT EMPLOYERS

An employer may be included as a Participant Employer if the Policyholder and Hartford Life so agree. Hartford Life
will keep a list of accepted Participant Employers and the effective dates of coverage for each.

The Policyholder may act for or on behalf of all Participant Employers in all matters of the policy. The following will
be binding on all Participant Employers:

e all agreements between Hartford Life and the Policyholder;

e all notices from Hartford Life to the Policyholder; and

e all notices from the Policyholder to Hartford Life.

An employee of a Participant Employer will be deemed to be an employee of the Policyholder for insurance purposes.

Coverage for a Participant Employer wil! terminate on the first to occur of:

« the date his premium is due, but not paid; or

e the date on which the Policyholder wants the employer to be removed from the policy. Such date must be stated
in written notice to Hartford Life, and must be after the date of the notice.

GR-11383-HLA(@) PI-2.00

Booklet-Certificate
The Booklet-certificate(s), and the endorsement form(s) enclosed therein, attached to this Policy are hereby
incorporated in, and made a part of, this policy.

Booklet Form(s):
207759GL)1.18

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
207759GL)17.3
207759(GL)18.3
207759(GL)1L9.3
207759(GL)20.2
207759(GL)21.3
207759(GL)22.2
207759(GL)23.2
207759(GL)24.2
207759(GL)4.17
207759(GL)5.12
207759(GL)6.5

207759GL)7.3

207759(GL)8.3

207759(GL)9.3

The terms found in the Booklet-certificate(s) will control:

e = the benefit plan provisions;

the eligibility and effective date of insurance rules;

the termination of insurance rules;

exclusions; and

other general policy provisions pertaining to state insurance law requirements.

INCORPORATION PROVISION

GR-11383-HLA(3)

PI-3.19

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