Document Date
Meeting Description
Document Type
Meeting Date
Page Number
94
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
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