QBE A&H
123 Pleasant Street, 3° Floor
Marblehead, MA 01945
Toli 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:
Policy Number:
QBE
City of Nashua, July 04, 2022
LGS02732-22
Thank you for selecting QBE Insurance Corporation for City of Nashua's Excess Loss Policy. We are pleased to have
the opportunity to service your client and hope to exceed your expectations.
Enclosed please find the appropnate documents for completion. In order to bind coverage, the following requirements
are needed.
e Signed and compieted Application for Excess Loss Policy
e First month’s premium: $154,693.00
e ACH Claims Reimbursement Authorization form for completion; Provides faster claim reimbursement
payment processing 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 prospective client is
located, in the producer's resident state, and will need to be appointed with QBE where required.
e Executed Plan Documentinclusive of signature page which states all the provisionsof the plan and
delineates the various responsibilities for financing the plan, the eligibility, and all the other aspects of the
pian (summary descriptions and certificates alone are not acceptable).
e Welcome to Expedited Reimbursement Program Flyer
We are requesting the following reporting to please be sent at your earliest convenance.
e Finallargeclaims through the effective date to include 50% reportlisting name(s) & diagnosis. updated
trigger, pre-certification and case management reports inclusive of RX reporting.
The following Endorsement(s) modify the Excess Loss Policy and will be provided upon Policy Issuance.
e Advance Reimbursement Endorsement
e €xpedited Reimbursement Endorsement
e New Hampshire State Specific Endorsement
e Rate Stabilization Endorsement (50%)
QBE and the links logo are registered service marks of QBE Insurance Group Limited.
UND3005 (11-21)
