Rate Renewal Period: | From: | To: | |
Date Submitted: | _____ | ||
Type of Filing (Check One Box) | □ New Group Contract | □ Revision of Existing Group Contract |
Current Rate (Composite per employee or per member) | $ per member per month |
Percentage Rate Change | % |
New Rate | $ per member per month |
Average Number of Enrollees Each Month During the Experience Period (If the average number of enrollees is equal to or less than fifty, explain why this is not a small group, as defined in RCW 48.43.005.) | |
Anticipated Loss Ratio | % |
Portion of carrier's total enrollment affected | % |
Portion of carrier's total premium revenue affected | % |
Experience Period | First Prior Period | Second Prior Period | |
From To | From To | From To | |
Member Months | |||
Billed Premium | |||
Incurred Claims | |||
Expenses | |||
Gain/Loss | |||
Experience Refund/Credit or Recoupment | |||
Earned Premium (Billed Premium -/+ Refund/Credit or Recoupment) | |||
Loss Ratio Percentage |
Attach comments or additional information. | |
Preparer's Information | |
Name: | |
Title: | |
Telephone Number: | |