Standard Transmittal Form - Accident and Health Insurance Form and Rate Submissions or Form Only Submissions
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
Forms 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:
If Rate Contact Information Is Different, Please Complete Page 2
Continue with Part 2