Board Of Aldermen

Jim Donchess

Mayor e City of Nashua
To: Board of Aldermen
From: Mayor Jim Donchess
Date: June 29, 2022
Re: Multi-Year Contract Award — Financial Auditing Services

Pursuant to NRO: § 5-74/B: A contract that extends from the current fiscal year into succeeding
fiscal year(s) in which no funds have been appropriated nor otherwise designated for this purpose
shall be approved by the full Board of Aldermen before the contract shall become binding on the
City.

Monthly Stop Loss Premium and
Enrollment Statement QBE

Reference

Policyholder Policy number Effective Date

City of Nashua LGS$02732-22 July 01, 2022

TPA Report period and date

Anthem

Premium remitted Report completed dy.

O Net or O Gross

Payment details

Specific coverage Covered units Adjusiments — Final units Rate Monthly cost
Composite 2050 x $75.46 =$

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

Page 4 of 4

3) Estimated Annual Aggregate Attachment Point: N/A
‘A. For Total Covered Units under 51 employees. amount entered cannot be less than the 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: WA
Per Covered Person.

12. YourPPO Network is: Blue Cross Blue Shield
13. Your Utilization Review Provider is: Anthem

14. Eligible for coverage:

Retirees: Yes [X] No[ ] Late Entrants: Yes [ ] No [X] Other - Retirees Pre-65 Only: Yes[X]No[ ]
15. Estimated Covered Units:

Covered Unit Description Units

Composite 2050

16, Initial premium deposit accompanying this Application:
$154,693.00

17. COVERAGES

QBE QBE INSURANCE CORPORATION

STATE OF DOMICILE: PENNSYLVANIA

APPLICATION FOR EXCESS LOSS INSURANCE POLICY

Policy Number: LGS02732-22

1,

10.

11.

Full legal name of Policyholder: Tax ID Number:
City of Nashua 02-6000581

(as it will appear in the Policy)

Principal Office Address:

229 Main Street Nashua, NH _ 03060
(street) icity) (state) (zip)

Contact Person: Kim Kleiner Email: kleinerki@nashuanh.gov

Nature of Business: 9111 Executive Offices

Also enclosed is the Premium & Enrollment statement. Premiurn is due on the first ofevery month. Please note that
premium must be remitted directly to the PO BOX address listed on the Premium & Enrollment statement. A
completed copy of this statementshould be remitted with each payment,

QGE A&H
123 Pleasant Street. 3‘ Floor

Marblehead M401945
Toll 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: City of Nashua, July 01, 2022

Policy Number: LGS02732-22

Thank you for selecting QBE Insurance Corporation for City of Nashuas Excess Loss Policy We are pleased to have
the opportunily lo service your cllentand hope to exceed yaur expectal ons.

we

Stop Loss Comparison for:

City of Nashua

City of Nashua

Administrative Services Division (603) 589-3020
229 Main Street - Nashua, NH 03060

Ta: Mayor Donchess
Finance Committee

Date: June 27, 2022
Re: Stop Loss Coverage FY23

This request is approval of a contract with QBE Insurance Corporation for the City of Nashua’s Excess
Loss Policy, otherwise known as Stop Loss.

Funding: Benefits Fund 13.6600.890- 59615 Stop Loss Coverage $1,905,516.