| ................................... | Date of filling out Form:.......... |
| ................................... |
| Space Reserved for Insurance | NEW JERSEY INSURER RATE FILING |
| Department Use | ADOPTION OF ADVISORY ORGANIZATION |
| PROSPECTIVE LOSS COSTS |
| FILING ADOPTION FORM |
| ................................... |
| 1. | INSURER NAME ........................................................... |
| ADDRESS ........................................................... |
| ............................................................ |
| ............................................................ |
| ............................................................ |
| ............................................................ |
| PERSON RESPONSIBLE FOR FILING ......................................... |
| TITLE .................................TELEPHONE #..................... |
| 2. | INSURER GROUP NAIC # .................................................. |
| 2A. | INSURER COMPANY NAIC # ................................................ |
| 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. |
| 7. | PROPOSED RATE LEVEL CHANGE ........% | EFFECTIVE DATE ......... |
| 8. | PRIOR RATE LEVEL CHANGE ........% | EFFECTIVE DATE ......... |
| 9. | ATTACH "FILING ADOPTION FORM" FOR EACH INSURER |
| IF SELECTED LOSS COST MULTIPLER IS DIFFERENT. |
| ** | The Field Loss Cost Level Change Factor for the initial filing is the |
| Ratio of Revised Loss Costs to Current Rates divided by the Deviation |
| which the insurer applied to the Current Rates (expressed as a decimal); |
| and for the subsequent filings, the Ratio Loss Cost Level |
| to Current Loss Cost Levels. |
| Insurer Name: ..................... | Date of filling out Form: ......... |
| NAIC #: Group: -......Company:- .... |
| NEW JERSEY INSURER RATE FILING |
| ADOPTION OF ADVISORY ORGANIZATION PROSPECTIVE LOSS COSTS |
| PROSPECTIVE LOSS COSTS |
| FILING ADOPTION FORM |
| CALCULATION OF LOSS COST MULTIPLIER |
| 10. | Line, Subline, Coverage, Territory, Class, etc. combination to which this |
| page applies: .......................................................... |
| 11. | Loss Cost Modification: |
| A. | The insurer hereby files to adopt the prospective loss costs in the |
| captioned reference filing: |
| (CHECK ONE) |
| Without modification. (Factor = 1.000) |
| With the following modification(s). (Cite the nature and percent |
| modification and attach supporting data and/or rationale for the |
| modification.) |
| ............................................................... |
| ............................................................... |
| B. | Loss Cost Modification Expressed as a Factor: ................ |
| (See examples below.) |
| NOTE: IF EXPENSE CONSTANTS ARE UTILIZED, ATTACH "EXPENSE CONSTANT SUPPLEMENT" OR OTHER SUPPORTING INFORMATION, AND DO NOT COMPLETE ITEMS 12-16 BELOW. |
| 12. Development of Expected Loss Ratio. (Attach exhibit detailing insurer expense data and/or other supportinginformation.) |
| Selected Provisions |
| A. | Total Production Expense | .................% |
| B. | General Expense | .................% |
| C. | Taxes, Licenses & Fees | .................% |
| D. | Profit & Contingencies * | .................% |
| E. | Other (explain) | .................% |
| F. | TOTAL | .................% |
| 15. | Company Current Loss Cost Multiplier (Only on subsequent Loss Cost |
| Filings): ................................ |
| 16. | Rate level change for the coverages to which this page applies:...% |
| i.e. [(14B/15) x Filed Loss Cost Level Change Factor - 1.00]. |
| Note that for the initial Loss Cost Filing, Item 15 = 1.000). |
| Example 1: Loss Cost modification factor: If your company's loss cost |
| modification is - 10%, a factor of 0.9 (1.000 - .100) should be used. |
| Example 2: Loss Cost modification factor: If your company's loss cost |
| modification is + 15%, a factor of 1.15 (1.000 + .150) should be used. |
| *This should reflect investment income. |