Monthly Stop Loss Premium and
Enrollment Statement QBE
Reference
Policyholder Policy number Effective Date
City of Nashua LGS02732-22 July 01, 2022
TPA Report period and date
Anthem
Premium remitted: Report completed by:
O Net or O Gross
Payment details
Specific coverage Covered units Adjustments — Final units Rate Monthly cost
Composite 2050 x $75.46 =$
Total monthly Specific premium $
Total Premium $
Premium is due on the first of the month. The Policy is subject to cancellation without prior notice if premiums are received past the 31
day grace period.
Prior month adjustments are limited to the preceding three months. Please attach explanation to receive consideration for any
other prior months. Enrollment counts should include COBRA participants and retirees, if applicable. All premium and enrollment
questions should be directed to QBE at 1.800.742.9279.
Any acceptance by QBE of late payments shall not be deemed a waiver of its rights to terminate this Policy for any future failure of Policyholder to make
timely payments.
Payment instructions
Please make checks payable to QBE Insurance Corporation.
For payments made by regular mail:
QBE North America
P.O. Box 28034
New York, NY 10087-8034
For payments made by ACH/wire:
JPMorgan Chase NA
Routing # 021000021
SWIFT: CHASEUS33
Account # 339792571
Account Name: QBE Insurance Corporation Concentration Account
Please remit backup documentation at time of transfer to: Premium@qbeah.com
For overnight payments:
JPMorgan Chase NA
Attn: QBE Lockbox 28034
4 Chase Metrotech Center, 7" Floor East
Brooklyn, NY 11245
