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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:
 
 
 
[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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