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284-43-6520  <<  284-43-6540 >>   284-43-6560

PDFWAC 284-43-6540

Summary for group contract filings other than small group contract filings.

Groups Other Than Small Groups Filing Summary
Carrier Name
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:
Date Submitted:
Type of Filing (Check One Box)
□ New Group
□ 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
From To
From To
From To
Member Months
Billed Premium
Incurred Claims
Experience Refund/Credit or Recoupment
Earned Premium (Billed Premium -/+ Refund/Credit or Recoupment)
Loss Ratio Percentage
Attach comments or additional information.
Preparer's Information
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.]
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