N.H. Admin. Code Ins, ch. Ins 2800, pt. Ins 2801, form FORM RFF-1
Date:
PROSPECTIVE LOSS COSTS REFERENCE FILING ADOPTION FORM
1. INSURER NAME _____________________________________________________________________
ADDRESS _______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
PERSON RESPONSIBLE FOR FILING ________________________________________________
TITLE ______________________TELEPHONE # ________________________________________
2. NAIC COMPANY # ________________________ NAIC GROUP #_____________________________
3. LINE OF INSURANCE _________________________________________________________________
4. ADVISORY ORGANIZATION ___________________________________________________________
5. ADVISORY ORGANIZATION REFERENCE FILING # _______________________________________
6. The above insurer hereby declares that it is a member, subscriber or service purchaser of the named advisory organization for this line of insurance. The insurer hereby files to be deemed to have independently submitted as its own filing the prospective loss costs in the captioned reference filing.
The insurer's rates will be the combination of the prospective loss costs and the loss cost multipliers and, if utilized, the expense constants specified in the attachments.
7. PROPOSED RATE LEVEL CHANGE ____% EFFECTIVE DATE ___________________
8. PRIOR RATE LEVEL CHANGE ____% EFFECTIVE DATE ________________________________
9. CHECK ONE OF THE FOLLOWING:
______The insurer hereby files to have its loss cost multipliers and, if utilized, expense constants be applicable to future revisions of the advisory organization's prospective loss costs for this line of insurance. The insurer's rates will be the combination of the advisory organization's prospective loss costs and the insurer's loss cost multipliers and, if utilized, expense constants specified in the attachments. The rates will apply to policies written on or after the effective date of the advisory organization's prospective loss costs. This authorization is effective until disapproved by the commissioner, or amended or withdrawn by the insurer.
______The insurer hereby files to have its loss costs multipliers and, if utilized, expense constants be applicable only to the above advisory organization reference filing.
I. CALCULATION OF COMPANY LOSS COST MULTIPLIER WITHOUT EXPENSE CONSTANT
1. Line, subline, coverage, territory, class, etc. combination to which this page applies _____________
________________________________________________________________________________________
2. Loss Cost Modification:
A. The insurer hereby files to adopt the prospective loss costs in the captioned reference filing:
Without modification. (factor=1.000)
With the following modification: _________%
(Cite the nature of the modification, and attached supporting data and rationale.)
_________________________________________________________________________
_________________________________________________________________________
B. Loss Cost Modification Expressed as a Factor: __________
3. Development of Expected Loss Ratio. (Attach exhibit detailing insurer expense data and/or other supporting information.
Selected Provisions
A. Total Production Expense ______________% (+)
B. General Expense ______________% (+)
C. Taxes, Licenses & Fees ______________% (+)
D. Underwriting Profit & Contingencies ______________% (+)
E. Investment Income ______________% (-)
F. Other (explain) ______________% (+)
G. TOTAL ______________%
4.
A. Expected Loss Ratio: ELR:ELR=100%- 3G ______________%
B. ELR in decimal form = ______________
5. Calculated Loss Cost Multiplier (1.00/4B)= ______________%
6. Company Selected Loss Cost Multiplier = ______________
Any difference between 5 and 6 should be explained on line 2.
7. Rate level change for the coverages to which this page applies. _____________%
II. CALCULATION OF COMPANY LOSS COST MULTIPLIER WITH EXPENSE CONSTANTS
1. Line, subline, coverage, territory, class, etc. combination to which this page applies __________
_____________________________________________________________________________________
2. Loss Cost Modification:
A. The insurer hereby files to adopt the prospective loss costs in the captioned reference filing:
Without modification. (factor=1.000)
With the following modification: _________%
(Cite the nature of the modification, and attached supporting data and rationale.)
_________________________________________________________________________
_________________________________________________________________________
B. Loss Cost Modification Expressed as a Factor: ____________________________________
3. Development of Expected Loss Ratio. (Attach exhibit detailing insurer expense data and/or other supporting information, including an explanation of the split between fixed and variable expenses.)
Selected Provisions
Overall | Variable | Fixed | |
A. Total Production Expense | _______ | _______ | ________(+) |
B. General Expense | _______ | _______ | ________(+) |
C. Taxes, Licenses & Fees | _______ | _______ | ________(+) |
D. Underwriting Profit & Contingencies | _______ | _______ | ________(+) |
E. Investment Income | _______ | _______ | ________(-) |
F. Other (explain) | _______ | _______ | ________(+) |
G. TOTAL | _______ | _______ | _________ |
Overall
Variable
Fixed
A. Total Production Expense
_______
_______
________(+)
B. General Expense
_______
_______
________(+)
C. Taxes, Licenses & Fees
_______
_______
________(+)
D. Underwriting Profit & Contingencies
_______
_______
________(+)
E. Investment Income
_______
_______
________(-)
F. Other (explain)
_______
_______
________(+)
G. TOTAL
_______
_______
_________
4.
A. Expected Loss Ratio (ELR): 100% - Overall 3G. = _________
B. ELR in decimal form = _________
C. Variable Expected Loss Ratio (VELR): 100%-Variable 3.G= _________
D. VELR in decimal form = _________
5.
A. Formula Expense Constant
(1.00/4B-1.00/4D) x Average Underlying Loss Cost = _________
B. Formula Variable Loss Cost Multiplier: (I.2.B ÷ III.2.D) = _________
C. Selected Expense Constant = _________
6.
A. Formula Variable Loss Cost Multiplier: (1.00/4D)= _________
B. Selected Variable Loss Cost Multiplier (2B/6A) = _________
7. Explain any differences between 5A and 5B.
Any difference between 6A and 6B should be explained on line 2. ________________________________________________________________________________
8. Rate level change for the coverages to which this page applies: ________%
N.H. Admin. Code Ins, ch. Ins 2800, pt. Ins 2801, form FORM RFF-1