Wash. Admin. Code § 284-43-6540
Current through Register Vol. 24-11, June 1, 2024
Groups Other Than Small Groups Filing Summary
| Carrier Name | ___________________________ |
| Address | ___________________________ |
| ___________________________ | |
| ___________________________ | |
| Contract Holder/Pool Category and Name (Check One Box) | [] Single Employer Group: |
| Employer Name: | |
| [] Multiemployer other than Association/Trust Groups | |
| Group Pool Name: | |
| [] Association/Trust Groups | |
| Association/Trust Group Name: | |
| Contract Form Number | ____________________ |
| Rate Form Number (if different from Contract Form Number) | ____________________ |
| Product Name | ____________________ |
If additional space is required to list the contract/rate form number and product name, attach a separate sheet.
| Rate Renewal Period: | From: ________ | To: _________ | |
| Date Submitted: | _____ | ||
| Type of Filing (Check One Box) | [] New Group Contract | [] Revision of Existing Group Contract |
Proposed Rate Schedules: Attach a separate sheet to list all proposed tier rates.
Rate Summary
| Current Rate (Composite per employee or per member) | $ per member per month |
| Percentage Rate Change | % |
| New Rate | $ per member per month |
| Average Number of Enrollees Each Month During the Experience Period (If the average number of enrollees is equal to or less than fifty, explain why this is not a small group, as defined in RCW 48.43.005.) | _____________ |
| Anticipated Loss Ratio | % |
| Portion of carrier's total enrollment affected | % |
| Portion of carrier's total premium revenue affected | % |
Summary of Contract Experience
| Experience Period | First Prior Period | Second Prior Period | |
| From To | From To | From To | |
| Member Months | |||
| Billed Premium | |||
| Incurred Claims | |||
| Expenses | |||
| Gain/Loss | |||
| Experience Refund/Credit or Recoupment | |||
| Earned Premium (Billed Premium -/+ Refund/Credit or Recoupment) | |||
| Loss Ratio Percentage |
| Attach comments or additional information. | |
| Preparer's Information | |
| Name: | ________________ |
| Title: | ________________ |
| Telephone Number: | ________________ |
Wash. Admin. Code § 284-43-6540
Statutory Authority: RCW 48.02.060, 48.44.050, 48.46.200, 48.44.020 (2)(d), 48.44.022, 48.44.023, 48.46.060 (3)(d) and (5), 48.46.064, 48.46.066, and 2015 c 19.