Standard Transmittal Form - Accident and Health Insurance Rate Only Submissions (No Forms)
Submitting Company Information
Company Name
NAIC Number
Please choose the appropriate Insurer type	Article 43 Corporation Health Maintenance Organization Commercial Insurer-Individual (including franchise) Commercial Insurer-Group (including blanket) Municipal Cooperative Fraternal Benefit Society
Date of Transmittal
Contact Information
Contact Person (If contact person is not a Submitting Company employee, please include a copy of the authorization to act on behalf of the Submitting Company)
Name:
Title:
Company:
Address 1:
Address 2:
City:
State:
Zip Code:
Phone Number:
Phone extension:
Fax Number:
E-mail Address:

Continue with Page 2