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Standard Transmittal Forms

Accident and Health Insurance for non-SERFF Filings

There are two standard transmittal forms.  There are links to all required subsidiary forms from within the primary form, you do not need to access the subsidiary forms directly. You can maneuver between the primary and subsidiary forms using the browser's "Back" button and the links within the primary form. The appropriate transmittal form and all completed subsidiary forms (blank forms need not be submitted) need to be printed separately and sent with the submission to the Health Bureau.

Form Notes

Primary Form for Form Only or Form and Rate Submissions

Standard Transmittal Form (Form Only or Form and Rate Submissions)

Subsidiary Forms

Primary Form for Rate Only Submissions

Standard Transmittal Form (Rate Only Submissions) Updated!

Subsidiary Forms

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