PDFWAC 284-43-6540
Summary for group contract filings other than small group contract filings.
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: | |