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

Submission Description Information (Specific)

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 HMO / POS
Individual and Group
For All Submissions: Provide General Description of This Submission
For All Submissions: Provide Detailed Information Pertaining to Forms Submitted
If previously approved or pending forms are being replaced: Provide Detailed Information Pertaining to Forms Replaced
Please confirm inclusion of the following:
(please explain any omissions in the general description of the filing)
All Submissions:
A Certification that all Forms (including applications) meet or exceed the minimum Flesch Reading Ease Test score of 45
Two copies of the entire submission

Form and Rate submissions:
An actuarial certification
An actuarial memorandum
Expected Loss Ratio calculation
Schedule of Commissions and Fees