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

All forms are in HTML format.
When selecting links on the forms themselves, a new browser window with the next form inside will appear.
When printing the forms, select detail forms require setting the "Page Setup" (via "File" menu in your browser's menubar) to Landscape and Legal Size paper - denoted by (LLS).
If you need to reset the form to its original state (removing all information entered on the form), select the Clear Form button (end of the form).

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!