N.H. Admin. Code Ins, ch. Ins 1200, pt. Ins 1201, app I
Form A
CREDIT INSURANCE REPORT TO THE
State of NEW HAMPSHIRE For the Year ____________ Reporting Company _________________
(to be filed on or before June 1)
Class of Business: | () Credit Unions | Plans of Benefits: | () Credit Life (Check one item in each of the next three boxes) |
() Commercial or Savings Bank | () Single Premium () Monthly Outstanding Balance | ||
() Finance Companies | () Single Life () Joint Life | ||
() Motor Vehicle Dealers | () Decreasing () Level | ||
() Other Sales Finance | () Credit Accident and Health (Check one item in each of the next three boxes) | ||
() Other: ___________ (please specify) | Elimination Period () 14 Day() 30 Day | ||
() Retroactive () Nonretroactive | |||
() Single Premium () Monthly Outstanding Balance | |||
() Single Life () Joint Life | |||
() Other: ___________ (please specify) |
Credibility Data for the Three Year Experience Period:
Number of Life Years: _________________
Incurred Claim Count: _________________
COMPANY EXPERIENCE - STATE ONLY
Calendar Year: | TOTAL |
1. Actual Earned Premiums at Rates in use. | |
a. Gross Premium Written | |
b. Refund on Termination | |
c. Net (a-b) | |
d. Premiums due but unpaid, beginning of period | |
e. Premiums due but unpaid, end of period | |
f. Premium reserve, beginning of period | |
g. Premium reserve, end of period | |
h. Earned Premiums (c-d+e+f-g) | |
2. Incurred Claims | |
a. Claims Paid | |
b. Unreported claims, beginning of period | |
c. Unreported claims, end of period | |
d. Claim reserve, beginning of period | |
e. Claim reserve, end of period | |
f. Incurred Claims (a-b+c+d-e) | |
3. Investment Income |
4. Instructional Notes:
a. With respect to the insurer's credit insurance experience that is to be reported on Form A pursuant to Ins 1201.11, each company is to submit a separate Form A for each plan of benefits that is written for each separate class of business.
b. The Form A should not include any experience reported in the same year under Form B.
c. The calendar years to be shown above are the three calendar years preceding the year in which the report is due.
d. State only experience is to be shown.
e. Investment income for each year is to be calculated according to the formula appearing in Ins 1201.10. The beginning and ending premium reserves to be reported in items 1.f and 1.g. shall be the unearned premium reserves attributable to single premiums paid. Statutory reserves are not to be reported or used in calculating investment income.
f. A list of all accounts is to be attached.
g. Name of person the department can contact: _________________________________
Telephone Number:___________________________________________________
Report completed by: ____________________________________
Title: _________________________________________________
Date: _________________________________________________
h. Send to the attention of the Life, Accident and Health Division.
N.H. Admin. Code Ins, ch. Ins 1200, pt. Ins 1201, app I