3) Estimated Annual Aggregate Attachment Point: N/A
* A. For Total Covered Units under51 employees, amount entered cannot be less thanthe greater of:
(1) $6,200 times the number of Covered Persons;
(2) 120% of expected claims; or
(3) $31,000.
B. For Total Covered Units over 50 employees, amount entered cannot be less than 110% of expected claims
4) Minimum Annual Aggregate Attachment Point Percentage: N/A
5) Estimated Minimum Annual Aggregate Attachment Point: N/A
6) Individual Claim Limit: N/A
Per Covered Person.
7) Aggregate Policy Period Maximum Reimbursement (per Policy Period): N/A
8) Basis of Aggregate Excess Loss coverage benefit payment (Benefit Period):
Plan Benefits Incurred from N/A through N/A
and paid from N/A through N/A.
Plan Benefits incurred prior to the Effective Date (Run-In-Period) will be limited to:
N/A per Covered Person
N/A for all Covered Persons combined
9) Premium Rates (per month): N/A
10) Estimated Annual Aggregate Premium: N/A.
18. Special Limitations and Additional Information: N/A.
You have read the foregoing and understand and agree with the terms and conditions of the coverage as set
forth by Us and as reflected in the Application. You represent that You have formed Your Employee Benefit
Plan in compliance with all applicable state and federal laws. It is agreed that the statements in the
Application or in any materials submitted with this Application or attached to it, including all disclosure
information, are Your representations and shall be deemed material to acceptance of the risk by Us and that
the Policy is issued by Us in reliance on the truth and accuracy of such representations. Should subsequent
information become known which, if known prior to issuance of the Policy, would affect the premium rates,
factors, terms or conditions for coverage thereunder, We will have the right to revise the premium rates,
factors, terms or conditions as of the Effective Date, by providing written notice to You. Any fraudulent
statement will render the Policy null and void and claims, if any, will be forfeited.
THIS APPLICATION DOES NOT BIND COVERAGE. Upon approval of the Application, the Policy evidencing that
the coverage is in force will be issued by Us. Coverage will commence on the Effective Date set forth in the Policy.
This Application will attach to and form part of the Policy.
FRAUD WARNING: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, submits
an application for insurance or makes any claim for the proceeds of an insurance policy containing any false,
incomplete or misleading information may be guilty of insurance fraud.
AH-MSL-1001-NH (11-21) © QBE, 2021 Page 3 of 4
