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.
- 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
- General Information
- Out of State Filing Information
- Premium Rate Compliance
- Prior Approval With Certification Filing Information
- Rate Contact Information
- Regulation 123 Filing Information
- Replacement Detail
- Submission Detail (LLS)
- Submission Detail - 2nd page (if necessary) (LLS)
- Submission Detail - 3rd page (if necessary) (LLS)
- Submission Detail - 4th page (if necessary) (LLS)