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: | |
| |
[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. WSR 16-03-018 (Matter No. R 2015-04), § 284-43-6540, filed 1/8/16, effective 1/8/16.]