Document Date
Meeting Description
Document Type
Meeting Date
Page Number
256
ACCEPTED BY THE POLICYHOLDER:
Signed at
Policyholder (correct legal name)
Date
By (Officer's signature and title)
(Print Name)
Signature Broker/Agent of Record
(Print Name)
ACCEPTED BY THE COMPANY:
Signed at Marblehead, Massachusetts
On behalf of the Company
Date Tara Krauss, Head of A&H
By (Officer's name and title)
AH-MSL-1001-NH (11-21) © QBE, 2021 Page 4 of 4
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