QGE A&H
123 Pleasant Street. 3‘ Floor
Marblehead M401945
Toll 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: City of Nashua, July 01, 2022
Policy Number: LGS02732-22
Thank you for selecting QBE Insurance Corporation for City of Nashuas Excess Loss Policy We are pleased to have
the opportunily lo service your cllentand hope to exceed yaur expectal ons.
Enclosed please find the appropnate documents for completion In order to bind coverage, the following requirements
are needed
e Signed and completed Application for Excess Loss Policy
« Firstmonth’s premium: $154,693.00
e ACH Claims Reimbursement Authorization form for completion: Provides faster claimrembursement
paymentprocessing 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 prospectve clientis
localed in the producer's resident stale. and wil need to be appointed with QBE where required
« Executed Plan Documentinclusive of signature page which states all the provisionsofthe plan and
delineates the various responsibilities for financing the plan. the eligibility, and all the other aspects ofthe
plan (summary descriptions and certificates alone are not acceptable).
e Welcome to Expedited Remmbursement Program Flyer
We are requesting the following reporting to please be sent at your earliest convenance.
¢ Finallarge claims through the effective date to include 50% reportlistingnama(s) &diagnosis updated
trigger, pre-cert fication and case management reports inclusive of RX reporting
The following Endorsement(s} modrfy the Excess Loss Policy and will be provided upon Pancy Issuance
e Advance Reimbursement Endorsement
* Expedited Reimbursement Endorsement
e New Hampshire Stale Specific Endorsement
e = Rate Stabilization Endorsement (50%)
QBE and the links logo are registered service marks of QBE Insurance Group Limited
UND3005 (11-21)
