23 CAR pt. 200, Appendix A. Forms

FORM UT Property & Casualty Transmittal Document (Revised 1/1/06) 3. Group Name Group NAIC # 4. Company Name(s) Domicile NAIC # FEIN # 5. Company Tracking Number Contact Info of Filer(s) or Corporate Officer(s) [include toll-free number] 6. Name and address Title Telephone #s FAX # e-mail 7. Signature of authorized filer 8. Please print name of authorized filer Filing information (see General Instructions for descriptions of these fields) 9. Type of Insurance (TOI) 10. Sub-Type of Insurance (Sub-TOI) 11. State Specific Product code(s)(if applicable)[See State Specific Requirements] 12. Company Program Title (Marketing title) 13. Filing Type [ ] Rate/Loss Cost [ ] Rules [ ] Rates/Rules [ ] Forms [ ] Combination Rates/Rules/Forms [ ] Withdrawal [ ] Other (give description) 14. Effective Date(s) Requested New: Renewal: 15. Reference Filing? [ ] Yes [ ] No 16. Reference Organization (if applicable) 17. Reference Organization # & Title 18. Company’s Date of Filing 19. Status of filing in domicile [ ] Not Filed [ ] Pending [ ] Authorized [ ] Disapproved PC TD-1 pg 1 of 2 2. Insurance Department Use only a. Date the filing is received: b. Analyst: c. Disposition: d. Date of disposition of the filing: e. Effective date of filing: f. State Filing #: g. SERFF Filing #: 1. Reserved for Insurance Dept. Use Only Property & Casualty Transmittal Document 20. This filing transmittal is part of Company Tracking # 22. Filing Fees (Filer must provide check # and fee amount if applicable) [If a state requires you to show how you calculated your filing fees, place that calculation below] Check #: Amount: Refer to each state’s checklist for additional state specific requirements or instructions on calculating fees. ***Refer to the each state’s checklist for additional state specific requirements (i.e. # of additional copies required, other state specific forms, etc.) PC TD-1 pg 2 of 2 Filing Description [This area should be similar to the body of a cover letter and is free-form text] 21. FORM FILING SCHEDULE (This form must be provided ONLY when making a filing that includes forms) (Do not refer to the body of the filing for the forms listing.) 1. This filing transmittal is part of Company Tracking # 2. This filing corresponds to rate/rule filing number (Company tracking number of rate/rule filing, if applicable) 3. Form Name /Description/Synopsis Form # Include edition date Replacement Or withdrawn? If replacemen give form # it replaces Previous state filing number, if required by state [ ] Replacement 01 [ ] Withdrawn [ ] Neither [ ] Replacement 02 [ ] Withdrawn [ ] Neither 03 [ [ ] Replacement ] Withdrawn [ ] Neither [ ] Replacement 04 [ ] Withdrawn [ ] Neither [ ] Replacement 05 [ ] Withdrawn [ ] Neither [ ] Replacement 06 [ ] Withdrawn [ ] Neither [ ] Replacement 07 [ ] Withdrawn [ ] Neither [ ] Replacement 08 [ ] Withdrawn [ ] Neither [ ] Replacement 09 [ ] Withdrawn [ ] Neither [ ] Replacement 10 [ ] Withdrawn [ ] Neither To be complete, a form filing must include the following: 1. A completed Form Filing Schedule Document (PC FFS-1) (Do not refer to the body of the filing for the forms listing.) and, 2. A completed Property & Casualty Transmittal Document (PC TD-1), and 3. One copy of each form to be reviewed for the reviewer’s records, and 4. One copy of any other components/exhibits submitted with the filing, and 5. The appropriate state Review Requirements, if required, and 6. The appropriate filing fees, if required, and 7. A postage-paid, self-addressed envelope large enough to accommodate the return. 8. You should refer to the each state’s checklist for additional state specific requirements (i.e. # of additional copies required, other state specific forms, etc.) PC FFS-1 RATE/RULE FILING SCHEDULE (This form must be provided ONLY when making a filing that includes rate-related items such as Rate; Rule; Rate & Rule; Reference; Loss Cost; Loss Cost & Rule or Rate, etc.) (Do not refer to the body of the filing for the component/exhibit listing.) 1. This filing transmittal is part of Company Tracking # 2. This filing corresponds to form filing number (Company tracking number of form filing, if applicable) D Rate Increase D Rate Decrease D Rate Neutral (0%) 3. Overall percentage rate impact for this filing 4. Effect of Rate Filing – Written premium change for this program 5. Effect of Rate Filing – Number of policyholders 6. Filing Method (Prior Approval, File & Use, Flex Band, etc.) 7. Rate Change by Company Company Name Percentage Change for this program # of policyholders for this program Written premium for this program 8. Overall percentage of last rate revision 9. Effective Date of last rate revision 10. Filing Method of Last filing (Prior Approval, File & Use, Flex Band, etc.) 11. Exhibit Name/Description /Synopsis Rule # or Page # Replacement or withdrawn? Previous state filing number, if required by state 01 [ [ [ ] Replacement ] Withdrawn ] Neither 02 [ [ [ ] Replacement ] Withdrawn ] Neither 03 [ [ [ ] Replacement ] Withdrawn ] Neither 04 [ [ [ ] Replacement ] Withdrawn ] Neither 05 [ [ [ ] Replacement ] Withdrawn ] Neither To be complete, a rate/rule filing must include the following: 1. A completed Rate/Rule Filing Transmittal document (PC RRFS-1) (Do not refer to the body of the filing for the component/exhibit listing.) and, 2. A completed Property & Casualty Transmittal Document (PC TD-1) and, 3. One copy of all rate/rule components/exhibits submitted with the filing, and 4. The appropriate state review requirements, if required, and 5. The appropriate filing fees, if required, and 6. A postage-paid, self-addressed envelope large enough to accommodate the return 7. You should refer to the each state’s checklist for additional state specific requirements (i.e. # of additional copies required, other state specific forms, etc.) PC RRFS-1 w:\mar03\cmte\ex\wg\isbs\fsumsg\Web Docs\PC Transmittal 11-25-02.doc 5 FORM F-1 Additional Forms 16. Form Filing Attachment This filing transmittal is part of company tracking number This filing corresponds to rate filing company tracking number Document Name Form Number Replaced Form Number Description Previous State Filing Number # [ ] Initial [ ] Revised [ ] Other # [ ] Initial [ ] Revised [ ] Other # [ ] Initial [ ] Revised [ ] Other # [ ] Initial [ ] Revised [ ] Other # [ ] Initial [ ] Revised [ ] Other # [ ] Initial [ ] Revised [ ] Other # [ ] Initial [ ] Revised [ ] Other # [ ] Initial [ ] Revised [ ] Other © 2004 National Association of Insurance Commissioners Page_# W:\Mar04\Cmte\Ex\wg\isbs\FSUMSG\TransmittalForms\Additional Forms Attachment.doc 6 FORM RF-1 Rate Filing Abstract NAIC LOSS COST DATA ENTRY DOCUMENT 1. This filing transmittal is part of Company Tracking # 2. If filing is an adoption of an advisory organization loss cost filing, give name of Advisory Organization and Reference/ Item Filing Number Company Name Company NAIC Number 3. A. B. Product Coding Matrix Line of Business (i.e., Type of Insurance) Product Coding Matrix Line of Insurance (i.e., Sub-type of Insurance) 4. A. B. 5. (A) COVERAGE (See Instructions) (B) Indicated % Rate Level Change (C) Requested % Rate Level Change FOR LOSS COSTS ONLY (D) Expected Loss Ratio (E) Loss Cost Modification Factor (F) Selected Loss Cost Multiplier (G) Expense Constant (If Applicable) (H) Co. Current Loss Cost Multiplier TOTAL OVERALL EFFECT 6. 5 Year History Rate Change History 7. 8. Apply Lost Cost Factors to Future filings? (Y or N) 9. Estimated Maximum Rate Increase for any Insured (%). Territory (if applicable): 10. Estimated Maximum Rate Decrease for any Insured (%) Territory (if applicable): PC RLC U:LossCostDraft/DataEntry.doc Year Policy Count % of Change Effective Date State Earned Premium (000) Incurred Losses (000) State Loss Ratio Countrywide Loss Ratio Expense Constants Selected Provisions A. Total Production Expense B. General Expense C. Taxes, License & Fees D. Underwriting Profit & Contingencies E. Other (explain) F. TOTAL 7 FORM RF2- Reference filing abstract NAIC LOSS COST FILING DOCUMENTOTHER THAN WORKERS’ COMPENSATION CALCULATION OF COMPANY LOSS COST MULTIPLIER This filing transmittal is part of Company Tracking # This filing corresponds to form filing number (Company tracking number of form filing, if applicable) ( ) Loss Cost Reference Filing ( ) Independent Rate Filing (Advisory Org, & Reference filing #) 1. Check one of the following: The insurer hereby files to have its loss cost multipliers and, if utilized, expense constants be applicable to future revisions of the advisory organization’s prospective loss costs for this line of insurance. The insurer’s rates will be the combination of the advisory organization’s prospective loss costs and the insurer’s loss cost multipliers and if utilized, expense constants specified in the attachments. The rates will apply to policies written on or after the effective date of the advisory organization’s prospective loss costs. This authorization is effective until disapproved by the Commissioner, or until amended or withdrawn by the insurer. Note: Some states have statutes that prohibit this option for some lines of business. The insurer hereby files to have its loss cost multipliers and, if utilized, expense constants be applicable only to the above Advisory Organization Reference Filing. 2. Line, Subline, Coverage, Territory, Class, etc. combination to which this page applies: 3. Loss cost modification: A. The insurer hereby files to adopt the prospective loss costs in the captioned reference filing (Check One): ( ) Without Modification (factor = 1.000) ( ) With the following modification(s). (Cite the nature and percent modification, and attach supporting data and/or rationale for the modification.) B. Loss Cost Modification Expressed as a Factor: (See Examples Below) Example 1: Loss cost Modification Factor: If your company's loss cost modification is -10%, a factor of .90 (1.000 - .100) should be used. Example 2: Loss cost Modification Factor: If your company's loss cost modification is =15%, a factor of 1.15 (1.000 + .150) should be used. NOTE: IF EXPENSE CONSTANTS ARE UTILIZED ATTACH “EXPENSE CONSTANT SUPPLEMENT” OR OTHER SUPPORTING INFORMATION. DO NOT COMPLETE ITEMS 4-8 BELOW. 4. Development of Expected Loss Ratio. (Attach exhibit detailing insurer expense data and/or other supporting information. Selected Provisions A. Total Production Expense % B. General Expense % C. Taxes, Licenses & Fee % D. Underwriting profit & Contingencies (explain how investment income is taken into account) % E. Other (explain) % F. Total % 5. 6. 7. 8. PC IRF A. Expected Loss Ratio: ELR = 100% - 4F = A % B. ELR in Decimal Form = Company Formula Loss Cost Multiplier (3B/5B) Company Selected Loss Cost Multiplier = (Attach explanation for any differences between 6 and 7) Rate Level Change for the coverage(s) to which this page applies If this is a loss cost filing adopting an advisory organization’s loss costs, the above insurer hereby declares that it is a member, subscriber or service purchaser of the named advisory organization for this line of insurance. The insurer hereby files (to be deemed to have independently submitted as its own filing) the prospective loss costs in the captioned Reference Filing. The insurer's rates will be the combination of the prospective loss costs and the loss cost multipliers and, if utilized, the expense constants specified in the attachments. 8 FORM RF-WC NAIC LOSS COST FILING DOCUMENTFOR WORKERS’ COMPENSATION CALCULATION OF COMPANY LOSS COST MULTIPLIER This filing transmittal is part of Company Tracking # This filing corresponds to form filing number (Company tracking number of form filing, if applicable) ( ) Loss Cost Reference Filing ( ) Independent Rate Filing (Advisory Org, & Reference filing #) 1. Check one of the following: 2. Does this filing apply to all class codes? If no, complete a copy of this form for each affected class with appropriate justification. 3. Loss cost modification: A. The insurer hereby files to adopt the prospective loss costs in the captioned reference filing: (Check One) ( ) Without Modification (factor = 1.000) ( ) With the following modification(s). (Cite the nature and percent modification, and attach supporting data and/or rationale for the modification.) B. Loss Cost Modification Expressed as a Factor: (See Examples Below) Example 1: Loss cost Modification Factor: If your company's loss cost modification is -10%, a factor of .90 (1.000 - .100) should be used. Example 2: Loss cost Modification Factor: If your company's loss cost modification is =15%, a factor of 1.15 (1.000 + .150) should be used. NOTE: IF EXPENSE CONSTANTS ARE UTILIZED ATTACH “EXPENSE CONSTANT SUPPLEMENT” OR OTHER SUPPORTING INFORMATION. DO NOT COMPLETE ITEMS 4-11 BELOW. 4. Development of Expected Loss and Loss Adjustment Expense (Target Cost) Ratio. (Attach exhibit detailing insurer expense data, impact of premium discount plans, and/or other supporting information.) PROJECTED EXPENSES: Compared to standard premium at company rates. Selected Provisions A. Total Production Expense % B. General Expense % C. Taxes, Licenses & Fee % D. Underwriting profit & contingencies* % E. Other (explain) % F. Total % * Explain how investment income is taken into account 5. A. Expected Loss Ratio: ELR = 100% - 4F = B. ELR in Decimal Form = PC IRF-WC CONTINUED ON PAGE 2 If this is a loss cost filing adopting an advisory organization’s loss costs, the above insurer hereby declares that it is a member, subscriber or service purchaser of the named advisory organization for this line of insurance. The insurer hereby files (to be deemed to have independently submitted as its own filing) the prospective loss costs in the captioned Reference Filing. The insurer's rates will be the combination of the prospective loss costs and the loss cost multipliers and, if utilized, the expense constants specified in the attachments. The insurer hereby files to have its loss cost multipliers and, if utilized, expense constants be applicable only to the above Advisory Organization Reference Filing. The insurer hereby files to have its loss cost multipliers and, if utilized, expense constants be applicable to future revisions of the advisory organization’s prospective loss costs for this line of insurance. The insurer’s rates will be the combination of the advisory organization’s prospective loss costs and the insurer’s loss cost multipliers and if utilized, expense constants specified in the attachments. The rates will apply to policies written on or after the effective date of the advisory organization’s prospective loss costs. This authorization is effective until disapproved by the Commissioner, or until amended or withdrawn by the insurer. Note: Some states have statutes that prohibit this option for some lines of business. 9 NAIC LOSS COST FILING DOCUMENTFOR WORKERS’ COMPENSATION 6. Overall Impact of Expense Constant and Minimum Premiums: (a 2.3% impact would be expressed as 1.023) 7. Overall Impact of Size-of-Risk Discounts plus Expense Graduation Recognition in Retrospective Rating: (An 8.6% average discount would be expressed as 0.914) 8. Company Formula Loss Cost Multiplier [3B / ((7 – 4F) X 6)] 9. Company Selected Loss Cost Multiplier = (Attach explanation for any differences between 6 and 7) 10. Are you amending your minimum premium formula? If yes, attach documentation, Yes No including rate level impact as well as changes in multipliers, expense constants, ( ) ( ) maximum, etc. 11. Are you changing your premium discount schedules? If yes, attach schedules ( ) ( ) and support, detailing premium or rate level changes. PC IRF-WC 10 ARKANSAS INSURANCE DEPARTMENT FORM A-1 PRIVATE PASSENGER AUTOMOBILE ABSTRACT Instructions: All questions must be answered. If the answer is “none” or “Not applicable, so state. If all questions are not answered, the filing will not be accepted for review by the Department. Use a separate abstract for each company if filing for a group. Subsequent private passenger auto rate/rule submissions that do not alter the information contained herein need not include this form. Company Name NAIC # (including group #) 1. Are there any areas in the State of Arkansas in which your company will not write automobile insurance? Yes No If yes, list the areas: 2. Do you furnish a market for young drivers? Yes No 3. Do require collateral business to support a youthful driver? Yes No 4. Do you insure drivers with an international or foreign driver’s license? Yes No 5. Specify the percentage you allow in credit or discounts for the following: a. Driver over 55 % b. Good Student Discount % c. Multi-car Discount % d. Accident Free Discount* % Please Specify Qualification for Discount: e. Anti-Theft Discount % f. Other (specify) % % % % 6. Do you have an installment payment plan for automobile insurance? Yes No If so, what is the fee for installment payments? 7. Does your company utilize a tiered rating plan? Yes No If so, list the programs and percentage difference and current volume for each plan: Program Percentage Difference Volume THE INFORMATION PROVIDED IS CORRECT TO THE BEST OF MY KNOWLEDGE AND BELIEF. Signature Printed Name Title Telephone Number Email address AID PC A-1 (1/06) 11 ARKANSAS INSURANCE DEPARTMENT FORM H-1 HOMEOWNERS ABSTRACT INSTRUCTIONS: All questions must be answered. If the answer is "none" or "not applicable", so state. If all questions are not answered, the filing will not be accepted for review by the Department. Use a separate abstract for each company if filing for a group. Subsequent homeowners rate/rule submissions that do not alter the information contained herein need not include this form. Company Name NAIC # (including group #) 1. If you have had an insurance to value campaign during the experience filing period, describe the campaign and estimate its impact. If you use a cost estimator (or some similar method) in order to make sure that dwellings (or 2. contents) are insured at their value, state when this program was started in Arkansas and estimate its impact. If you require a minimum relationship between the amount of insurance to be written and the 3. replacement value of the dwelling (contents) in order to purchase insurance, describe the procedures that are used. 4. If you use an Inflation Guard form or similar type of coverage, describe the coverage(s) and estimate the impact. 5. Specify the percentage given for credit or discounts for the following: a. Fire Extinguisher % b. Burglar Alarm % c. Smoke Alarm % d. Insured who has both homeowners and auto with your company % e. Deadbolt Locks % f. Window or Door Locks % g. Other (specify) % % % 6. Are there any areas in the State of Arkansas In which your company will not write homeowners insurance? If so, state the areas and explain reason for not writing. 7. Specify the form(s) utilized in writing homeowners insurance. Indicate the Arkansas premium volume for each form. Form Premium Volume AID PC H-1 (1/06) Page 1 of 2 12 Form H-1 (1/06) Page 2 of 2 8. Do you write homeower risks which have aluminum, steel or vinyl siding? 9. Is there a surcharge on risks with wood heat? If yes, state the surcharge Does the surcharge apply to conventional fire places? If yes, state the surcharge Yes No THE INFORMATION PROVIDED IS CORRECT TO THE BEST OF MY KNOWLEDGE AND BELIEF. Signature Printed Name Title Telephone Number Email address AID PC H-1 (1/06) 13 Form PPANOT Rev. 1/1/2006 ARKANSAS INSURANCE DEPARTMENT NOTICE OF RATE INCREASE (Private Passenger Auto) [INSURANCE COMPANY] has increased its overall rates for its [LINES OF COVERAGE] insurance business in Arkansas. The overall rate increase is %. Copies of the rate filing may be obtained by writing or calling the Arkansas Insurance Department, or by visiting our Internet site at http://www.insurance.arkansas.gov/PandC/divpage.htm. For more information, please contact the Department at: Arkansas Insurance Department Property & Casualty Division 1200 West Third Street Little Rock, AR 72201-1904 501-371-2800 14 Form HONOT Rev. 1/1/2006 ARKANSAS INSURANCE DEPARTMENT NOTICE OF RATE INCREASE (Homeowners) [INSURANCE COMPANY] has increased its overall rates for its [LINES OF COVERAGE] insurance business in Arkansas. The overall rate increase is %. Copies of the rate filing may be obtained by writing or calling the Arkansas Insurance Department, or by visiting our Internet site at http://www.insurance.arkansas.gov/PandC/divpage.htm. For more information, please contact the Department at: Arkansas Insurance Department Property & Casualty Division 1200 West Third Street Little Rock, AR 72201-1904 501-371-2800 15 Form PRONOT Rev. 1/1/2006 ARKANSAS INSURANCE DEPARTMENT NOTICE OF RATE INCREASE (Professional Liability) [INSURANCE COMPANY] has increased its overall rates for its [LINES OF COVERAGE] insurance business in Arkansas. The overall rate increase is %. Copies of the rate filing may be obtained by writing or calling the Arkansas Insurance Department, or by visiting our Internet site at http://www.insurance.arkansas.gov/PandC/divpage.htm. For more information, please contact the Department at: Arkansas Insurance Department Property & Casualty Division 1200 West Third Street Little Rock, AR 72201-1904 501-371-2800 16 Form PROMAL Rev. 1/1/2006 ARKANSAS INSURANCE DEPARTMENT NOTICE OF RATE INCREASE (Professional Liability) [INSURANCE COMPANY] has increased its overall rates for its [LINES OF COVERAGE] insurance business in Arkansas. The overall rate increase is %. Copies of the rate filing may be obtained by writing or calling the Arkansas Insurance Department, or by visiting our Internet site at http://www.insurance.arkansas.gov/PandC/divpage.htm. For more information, please contact the Department at: Arkansas Insurance Department Property & Casualty Division 1200 West Third Street Little Rock, AR 72201-1904 501-371-280 17 Private Passenger Auto Premium Comparision Survey Form FORM APCS - last modified August 2005 NAIC Number: Company Name: Assumptions to Use: 1 Liability -Minimum $25,000 per person 2 Bodily Injury $50,000 per accident $25,000 per accident 3 Property Damage $100 deductible per accident 4 Comprehensive & Collision $250 deductible per accident 5 The insured has elected to accept: Uninsured motorist property and bodily injury equal to liability coverage Underinsured bodily injury equal to liability coverage 6 Personal Injury Protection of $5,000 for medical, loss wages according to statute and $5,000 accidental Submit to: Arkansas Insurance Department Contact Person: 1200 West Third Street Telephone No.: Little Rock, AR 72201-1904 Email Address: Telephone: 501-371-2800 Effective Date: Email as an attachment insurance.pnc@arkansas.gov You may also attach to a SERFF filing or submit DISCOUNTS OFFERED: on a compact disk PASSIVE RESTRAINT/AIRBAG % % % % % AUTO/HOMEOWNERS GOOD STUDENT ANTI-THEFT DEVICE Over 55 Defensive Driver Discount $250/$500 Deductible Comp./Coll. % Fayetteville Trumann Little Rock Lake Village Pine Bluff Gender Female 18 Male 18 Male or Female 40 Male or Female 66 Female 18 Male 18 Male or Female 40 Male or Female 66 Female 18 Male 18 Male or Female 40 Male or Female 66 Female 18 Male 18 Male or Female 40 Male or Female 66 Female 18 Male 18 Male or Female 40 Male or Female 66 Vehicle Coverages Age 1999 Chevrolet Silverado 1500 2WD “LS” regular cab 119” WB Minimum Liability Minimum Liability with Comprehensive and Collision 100/300/50 Liability with Comprehensive and Collision 2003 Ford Explorer ‘XLT’ 2WD, 4 door Minimum Liability Minimum Liability with Comprehensive and Collision 100/300/50 Liability with Comprehensive and Collision 2003 Honda Odyssey ”EX” Minimum Liability Minimum Liability with Comprehensive and Collision 100/300/50 Liability with Comprehensive and Collision 2005 Toyota Camry LE 3.0L 4 door Sedan Minimum Liability Minimum Liability with Comprehensive and Collision 100/300/50 Liability with Comprehensive and Collision 2003 Cadillac Seville "STS" 4 door Sedan Minimum Liability Minimum Liability with Comprehensive and Collision 100/300/50 Liability with Comprehensive and Collision 1998 Chevrolet Cavalier LS 4D Sedan Minimum Liability Minimum Liability with Comprehensive and Collision 100/300/50 Liability with Comprehensive and Collision 18 NAIC Number: Company Name: Contact Person: Telephone No.: Email Address: Effective Date: Homeowners Premium Comparision Survey Form FORM HPCS - last modified August, 2005 Submit to: Arkansas Insurance Department 1200 West Third Street Little Rock, AR 72201-1904 USE THE APPROPRIATE FORM BELOW - IF NOT APPLICABLE, LEAVE Telephone: 501-371-2800 BLANK Email as an attachment to insurance.pnc@arkansas.gov You may also attach to a SERFF filing or submit on a cdr disk Survey Form for HO3 (Homeowners) - Use $500 Flat Deductible (Covers risk of direct physical loss for dwelling and other structures; named perils for personal property, replacement cost on dwelling, actual cash value on personal property) Public Protection Class Dwelling Value Washington Baxter Craighead St. Francis Desha Union Miller Sebastian Pulaski Brick Frame Brick Frame Brick Frame Brick Frame Brick Frame Brick Frame Brick Frame Brick Frame Brick Frame 3 $80,000 $120,000 $160,000 6 $80,000 $120,000 $160,000 9 $80,000 $120,000 $160,000 Survey Form for HO4 (Renters) - Use $500 Flat Deductible (Named perils for personal property, actual cash value for loss, liability and medical payments for others included) Public Protection Class Property Value Washington Baxter Craighead St. Francis Arkansas Union Miller Sebastian Pulaski Brick Frame Brick Frame Brick Frame Brick Frame Brick Frame Brick Frame Brick Frame Brick Frame Brick Frame 3 $5,000 $15,000 $25,000 6 $5,000 $15,000 $25,000 9 $5,000 $15,000 $25,000 Survey Form for DP-2 (Dwelling/Fire) - Use $500 Flat Deductible (Named perils for dwelling and personal property; replacement cost for dwelling, actual cash value for personal property, no liability coverage) Public Protection Class Dwelling Value Washington Baxter Craighead St. Francis Arkansas Union Miller Sebastian Pulaski Brick Frame Brick Frame Brick Frame Brick Frame Brick Frame Brick Frame Brick Frame Brick Frame Brick Frame 3 $80,000 $120,000 $160,000 6 $80,000 $120,000 $160,000 9 $80,000 $120,000 $160,000 SPECIFY THE PERCENTAGE GIVEN FOR CREDITS OR DISCOUNTS FOR THE FOLLOWING: EARTHQUAKE INSURANCE HO3 and HO4 only IMPORTANT, homeowners insurance does NOT automatically cover losses from earthquakes. Ask your agent about this co Fire Extinquisher Burglar Alarm Smoke Alarm % Deadbolt Lock % Window Locks % $1,000 Deductible % ARE YOU CURRENTLY WRITING EARTHQUAKE COVERAGE IN ARKANSAS? % WHAT IS YOUR PERCENTAGE DEDUCTIBLE? (yes or no) % % Other (specify) Zone Brick Frame % WHAT IS YOUR PRICE PER $1,000 OF COVERAGE? Highest Risk $ % Lowest Risk $ $ $ Maximum Credit Allowed Malpractice Premium Comparision Survey Form FORM MMPCS - last modified April, 2006 USE THE APPROPRIATE FORM BELOW - IF NOT APPLICABLE, LEAVE BLANK NAIC Number: Company Name: Contact Person: Telephone No.: Email Address: Effective Date: Submit to: Arkansas Insurance Department 1200 West Third Street Little Rock, AR 72201-1904 Telephone: 501-371-2800 Email as an attachment to insurance.pnc@arkansas.gov You may also attach to a SERFF filing or submit on a cdr disk Physicians Base Rate Hospital Clinic Private At 500,000/1,000,000 $ $ $ Discounts and Surcharges Emergency Room % % % Surgery % % % Delivery % % % Claims Free % % % Over 5 years Experience % % % Other: % % % Dental Base Rate Dentist Orthodontist Oral Surgeons At 100,000/300,000 $ $ $ Discounts and Surcharges Claims Free % % % 5 years Experience % % % Surgery % % % Other: % % % ARKANSAS CERTIFICATE OF COMPLIANCE (You may print or type the information required by this form) FORM SELFCERT I, , of (Name) (Title of Authorized Officer) (Name of Insurer) declare that I am authorized to execute and file this certificate of compliance and do hereby certify that I am knowledgeable of the legal requirements under Arkansas law applicable to the insurance forms that are the subject of this filing and further aver: 1. Upon information and belief, I certify that the insurance forms filed herewith are complete and comply with all Arkansas laws, including the: a. Arkansas Code Annotated; b. Arkansas Rules and Regulations; c. Arkansas Insurance Bulletins, Directives and Orders; d. Applicable filing requirements including the applicable product standards set forth in the product checklists; and e. Rulings and decisions of any court of this state. 2. I understand and acknowledge that the Commissioner will rely upon this certificate and if it is subsequently determined that any form filed herewith is false or misleading, appropriate corrective action shall be taken by the commissioner against the company. 3. Pursuant to Ark. Code Ann. § 23-79-109(a)(1)(C), I understand that by certifying that a form complies with paragraph 1 hereof, it is not to be taken by the undersigned or by my company as meaning that any insurance effected by use of such form may in any fashion be inconsistent with the statutory and common law of Arkansas. 4. Pursuant to Ark. Code Ann. §23-79-118, I understand and acknowledge that any insurance policy, rider, endorsement or other insurance form filed under this certificate, that is subsequently issued to an insured, and contains any condition or provision not in compliance with the requirements of the laws of the State of Arkansas, as set forth in paragraph 1 hereof, shall be construed and applied in accordance with such condition or provision as would have applied if the policy, rider, endorsement or form had been in full compliance with the law. If “NO”, to which companies does this Certification apply? Company Name(s) NAIC # Signature of Authorized Officer ► Name of Authorized Officer ► Title of Authorized Officer ► Email address of Authorized Officer ► Telephone # of Authorized Officer ► Date ► This form may be computer generated by the company. So long as the wording and general layout is the same, the format may vary. For more information, contact the Property & Casualty Division of the Arkansas Insurance Department at 1200 W 3rd St., Does this Certification apply to all the companies in this filing? (Yes or No) ► Company Tracking Number Little Rock, AR 72201, telephone: 501-371-2800, or email: information.pnc@arkansas.gov AID PC SelfCert (4/30/03)