N.H. Admin. Code Ins, ch. Ins 400, pt. Ins 401, app I
Life, Accident & Health, Annuity, Credit Transmittal Document (Revised 1/1/06)
| 1. | Prepared for the State of |
| 2. | Department Use Only |
| State Tracking ID | |
| 3. | Insurer Name & Address | Domicile | Insurer License Type | NAIC Group # | NAIC # | FEIN # |
| 4. | Contact Name & Address | Telephone # | Fax # | E-mail Address |
| 5. | Requested Filing Mode | Review & Approval File & Use Informational Combination (please explain): __________ Other (please explain): ___________ |
| 6. | Company Tracking Number | ||
| 7. | New SubmissionResubmission Previous file # ___________________ | ||
| 8. | Market | Individual Franchies | |
| Group | Small Large Small and Large _____________________________________ Employer Association Blanket Discretionary Trust Other:_________________ | ||
| 9. | Type of Insurance | ||
| 10. | Product Coding MatrixFiling Code | ||
| 11. | Submitted Documents | FORMS Policy Outline of Coverage Certificate Application/Enrollment Rider/Endorsement Advertising Schedule of Benefits Other Rates New Rate Revised Rate FILING OTHER THAN FORM OR RATE: Please explain: _________________________________________ SUPPORTING DOCUMENTATION Articles of Incorporation Third Party Authorization Association Bylaws Trust Agreements Statement of Variability Certifications Actuarial Memorandum Other_______________________________________________ | |
| 12. | Filing Submission Date | ||
| 13 | Filing Fee (If required) | Amount _________ Check Date _________ Retailatory Yes No Check Number | |
| 14. | Date Of Domiciliary Approval | ||
| 15. | Failing Description: | ||
| 16. | Certification (If required) | |||||||||||||
| I HEREBY CERTIFY that I have reviewed the applicable filing requirements for this filing, and the filing complies with all applicable statutory and regulatory provisions for the state of ____________. | ||||||||||||||
| Print Name ________________ | Title _____________________ | |||||||||||||
| Date: _____________________ | ||||||||||||||
| 17. | Form Filing Attachment | |||||||||||||
| This filing transmittal is part of company tracking number | ||||||||||||||
| This filing corresponds to rate filing company tracking number | ||||||||||||||
| Document Name | Form Number | Replaced Form Number | |
| Description | Previous State Filing Number | ||
| 01 | InitialRevisedOther ____________ | ||
| 02 | InitialRevisedOther ____________ | ||
| 03 | InitialRevisedOther ____________ | ||
| 04 | InitialRevisedOther ____________ | ||
| 05 | InitialRevisedOther ____________ | ||
| 06 | InitialRevisedOther ____________ | ||
| 07 | InitialRevisedOther ____________ | ||
| 08 | InitialRevisedOther ____________ | ||
| 09 | InitialRevisedOther ____________ | ||
| 10 | InitialRevisedOther ____________ |
| 18. | Rate Filing Attachment | |||
| This filing transmittal is part of company tracking number | ||||
| This filing corresponds to form filing company tracking number | ||||
| Overall percentage rate impact for this filing | % | |||
| Document Name | Affected Form Numbers | Previous State Filing Number | ||
| Description | ||||
| 01 | NewRevised Request +____% -____% Other ___________ | |||
| 02 | NewRevised Request +____% -____% Other ___________ | |||
| 03 | NewRevised Request +____% -____% Other ___________ | |||
| 04 | NewRevised Request +____% -____% Other ___________ | |||
| 05 | NewRevised Request +____% -____% Other ___________ | |||
| 06 | NewRevised Request +____% -____% Other ___________ | |||
| 07 | NewRevised Request +____% -____% Other ___________ | |||
| 08 | NewRevised Request +____% -____% Other ___________ | |||
| 09 | NewRevised Request +____% -____% Other ___________ | |||
| 10 | NewRevised Request +____% -____% Other ___________ | |||
Instruction Sheet for Life, Accident and Health, Annuity, Credit Transmittal Document
(*See state specific requirements prior to submitting filings to the respective state)
1. Prepared for the State of: ___________________ Indicate for which state the filing is being prepared.
2. Department Use Only
State Tracking ID - State assigned ID for internal purposes, if applicable.
Space available for state to input
3. Insurer Name & Address - Provide the insurance company name and address. This is the licensee name on the submitted forms.
State of Domicile - State of domicile for company.
Insurer License Type - The type of entity as listed on the Certificate of Authority or as licensed by the state to which the filing is being submitted. Examples include Life, HMO, Fraternal, Accident & Health, and Property & Casualty.
NAIC Group # - NAIC Group number (3 digits).
NAIC #NAIC Company code number (5 digits).
FEIN #Federal identification number.
4. Contact Name and Address - Compliance contact(s) for submission, company's name (if other than the insurer), and address for correspondence.
Telephone NumberTelephone number of the contact person.
Fax NumberFax number of the contact person.
E-mailE-mail address of the contact person.
If contact person is a third party filer, a letter of authorization must be submitted.
5. Requested Filing Mode - Indicate the type of filing review requested. Only one option may be selected. If Combination or Other is selected, an explanation is required.
6. Company Tracking Number Company's internal filing number or identifier. (If applicable)
7. New Submission or Resubmission - If resubmission, provide the state tracking number for the prior submission if it was provided by the state. If no state tracking number is available, and the prior filing was made in SERFF, provide the prior filing's SERFF Tracking Number. If neither is available, leave this blank.
8 . Market An identification of the targeted group or individuals. If Group, first select group size, then select one or more group types. If Other is selected, an explanation must be provided.
9. Type of Insurance List all applicable types utilizing the NAIC Uniform Life, Accident & Health, Annuity, Credit Product Coding Matrix. [Drafters note: To be provided upon adoption from the NAIC Product Coding sub group committee.]
10. Product Coding Matrix Filing Code Refer to the NAIC Uniform Life, Accident & Health, Annuity, Credit Product Coding Matrix. (www.naic.org)
11. Submitted Documents-
Mark ALL applicable boxes.
If filing forms, complete the Form Filing Attachment.
If filing rates, complete the Rate Filing Attachment.
If Filing Other Than Form or Rate is selected, identify what is being submitted and provide any required documents according to state regulations.
Provide explanation whenever Other is selected.
Submit the required number of copies according to state specific instructions
12. Filing Submission Date Date the filing is being submitted by the company.
13. Filing Fee (If required) - If a filing fee is required by the state for which the filing is being prepared, indicate the amount, whether retaliatory, check date, and check number. See State specific instructions.
14. Date of Domiciliary Approval Date filing was approved in domicile. If not approved, provide clarification.
15. Filing Description General description of the filing. This section replaces the body of the cover letter, and should be completed according to state specific instructions.
16. Certification (If required)-
A Certification indicating you have reviewed state filing requirements and complied with all applicable statutory and regulatory provisions for the state for which the filing is being prepared. See State specific instructions.
Provide name, title, date, and signature.
NOTE: No changes were required for the instructions to the Form and Rate schedules.
N.H. Admin. Code Ins, ch. Ins 400, pt. Ins 401, app I
The amended version of this appendix by New Hampshire Register Volume 37, Number 15, eff. 3/8/2017 is not yet available.