SCHEDULE OF INSURANCE
Schedule of Insurance
The Schedule(s) of Insurance for Group Insurance Policy GL-207759 listed below:
e = Basic Life Insurance
e Accidental Death, Dismemberment and Loss of Sight Benefit
e Supplemental Life Insurance
Booklet-Certificate
The Booklet-certificate(s), and the endorsement form(s) enclosed therein, attached to this Policy are hereby
incorporated in, and made a part of, this policy.
Booklet Form(s):
207759GL)1.18
PARTICIPANT EMPLOYERS
An employer may be included as a Participant Employer if the Policyholder and Hartford Life so agree. Hartford Life
will keep a list of accepted Participant Employers and the effective dates of coverage for each.
The Policyholder may act for or on behalf of all Participant Employers in all matters of the policy. The following will
be binding on all Participant Employers:
e all agreements between Hartford Life and the Policyholder;
e all notices from Hartford Life to the Policyholder; and
rg4 :
HE
HARTFORD
AMENDMENT TO GROUP POLICY GL-207759 PROCESSED ON FEBRUARY 24, 2015. ANY CHANGES
BETWEEN THIS POLICY AND THE PREVIOUSLY ISSUED POLICY ARE EFFECTIVE FEBRUARY 1,
2015. ALL OTHER TERMS, CONDITIONS AND DATES REMAIN UNCHANGED.
Name of Policyholder: CITY OF NASHUA, NEW HAMPSHIRE
Policy Number: Effective Date: Place of Delivery:
GL-207759 January 1, 1997 New Hampshire
Anniversary Dates: Premium Due Dates:
January 1 of each year, beginning in 2016. Monthly, on the first day of each policy month.
] Harvard Pilgrim Harvard Pilgrim Health Care includes Harvard Pilgrim Llealth Care,
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RATE PROPOSAL
Company Name: City of Nashua Effective Date: 07/01/2016 - 06/30/2017
Group Number: 027219 Plan ID : MD0000014789/RX0000011897
Product: NH HMO-Best Buy Plan Year Stand Alone Option
Rate Proposal terms and conditions
©P9 Harvard Pilerim
iy HealthCare’
Tlarvard Pilurim Wealth Care includes Harvard Pilgrim Health Care,
Harvard Pilgrio Health Care of Connecticut, Harvard Pilgrim
Tealth Care of New England and HPIIC Insurance Company.
RATE PROPOSAL
Company Name: City of Nashua
Group Number: 027219
Effective Date: 07/01/2016 - 06/30/2017
Plan ID :MD0000014789/RX0000011897
Product: NH HMO-Best Buy Plan Year Stand Alone Option
-T
Subtotal: Admin & Reinsurance
CAR Total (Claims & Admin &
10.
Purchaser:
FORM# PS_AO1
7.
(b)
(a)
and a set up fee of one hundred dollars ($100.00) for programming
costs and seventy-five dollars ($75.00) per hour for installation costs
associated with each request.
A quarterly report of enrollment status and activity by individual and
family subscriber, by group (may be provided in the form of a
monthly invoice for administration fees).
Annually
FORM# PS_A0O14
Reports.
(a)
(b)
(d)
(a)
(a)
