Standard Transmittal Form - Accident and Health Insurance
Form and Rate Submissions or Form Only Submissions

Submission Description Information (General)

Is this a new submission? New Submission
Resubmission - Prior File Number :
Submission Of Forms For Approval After Prefiling (11 NYCRR 52.32) - Prefiling File Number:
Is this a Deemer Filing (Section 3201(b)(6) and Circular Letter 2, 1998) No Yes - Required certification must be enclosed (see Circular Letter 2, 1998)
Is this a Prior Approval with Certification submission
(Circular Letter 4, 2003)
No Yes - Complete Additional Required Information
Please choose the appropriate filing type:
Please choose the applicable type of review being requested:
For Out-Of-State Filings (Section 3201(b)(2)): Complete list of states where forms will be used
For Certificates Deemed Delivered in New York
(Regulation 123 (11 NYCRR 59)) :
Complete Additional Required Information
Continue with Part 3