Standard Transmittal Form - Accident and Health Insurance
Rate Only Submissions (No Forms)
Submission Description Information
Is this a new submission? New Submission Resubmission - Prior File Number:
Is this a File And Use submission? No Yes, Section 3231(e) Yes, Section 4308(g)
Please choose the applicable type of review being requested:
Please choose the applicable type of coverage for this filing: Please include any necessary explanation in the General Description of the filing (see below)
For Certificates Deemed Delivered in NY (Regulation 123 (11 NYCRR 59)):

Complete Additional Required Information

Please confirm inclusion of the following:
(please explain any omissions in the general description of the filing (see below))
An actuarial certification
An actuarial memorandum or supporting rate material
Expected loss ratios
Two copies of the rate manual pages, rate schedules, or certified rate impact statement

Please indicate type of insurance product:

Large Group (51 or more) Small Group (50 or fewer)
Blanket Group Remittance Franchise 
Large & Small Group Individual (not HMO)
Standardized Individual HMO Only Standardized Individual POS
Individual and Group

For All Submissions:

Provide General Description of This Submission

Reference (for use in correspondence):