Agenda

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.

12.

13.
14.

15.

16.

17.

Your PPO Network is: Blue Cross Blue Shield

Your Utilization Review Provider is: Anthem

Eligible for coverage:

Retirees: Yes [X] No[ ] Late Entrants: Yes [ ] No [X]
Estimated Covered Units:
Covered Unit Description Units
Composite 2050

initial premium deposit accompanying this Application:
$154,693.00

COVERAGES

Other - Retirees Pre-65 Only: Yes [X] No[ ]

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 Policyhoider: 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) (city) (state) (zip)
Contact Person: Kim Kleiner Email: kleinerk@nashuanh.gov

Nature of Business:9111 Executive Offices

Also enclosed is the Premium & Enrollment statement. Premium is due on the first of every month. Please note that
premium must be remitted directly to the PO BOX address listed on the Premium & Enrollmentstatement. A
completed copy ofthis statement should be remitted with each payment.

QBE A&H

123 Pleasant Street, 3° Floor
Marblehead, MA 01945

Toli 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:

Policy Number:

QBE

City of Nashua, July 04, 2022
LGS02732-22

Stop Loss Comparison for:

City of Nashua

City of Nashua

Administrative Services Division

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

To: 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.

Jim Donchess
Mayor e City of Nashua

To: Board of Aldermen

From: Mayor Jim Donchess

Date: June 29, 2022

Re: Contract Award in Excess of $1M-— Excess Loss Insurance Coverage

Pursuant to NRO: § 5-74/B: E. Approval by the Finance Committee of a contract award in excess of
$1,000,000 shall be submitted to the full Board of Aldermen at its next regularly scheduled meeting
for final approval prior to award of the contract.

City of Nashua

Purchasing Department
Administrative Services Division (603) 589-3330
229 Main Street - Nashua, NH 03060 Fax (603) 594-3233

June 29, 2022
Memo #23-304

TO: Mayor Donchess
Finance Committee

SUBJECT: Excess Loss Insurance in the amount not to exceed $1,905,516 funded from 59165 Stop
Loss Coverage/Benefits Internal Service Fund

« If aggregate limits of less than $2,000,000 are imposed on bodily injury and property damage,
Contractor must maintain umbrella liability insurance of at least $1,000,000. All aggregates
must be fully disclosed on the required certificate of insurance.

« The specified insurance requirements do not relieve Contractor of its responsibilities or limit the
amount of its liability to the City or other persons, and Contractor is encouraged to purchase
such additional insurance, as it deems necessary.