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
