ND Insurance Department Bulletin 98-1
Policy, Form and Rate Filing Transmittal Form Effective July 1, 1998
[LOGO]
Glenn Pomeroy
Commissioner of Insurance
DEPARTMENT OF INSURANCE
STATE OF NORTH DAKOTA
# Bulletin 98-1
TO: All Insurance Companies
FROM: Glenn Pomeroy, Commissioner
Glenn Pomeroy
DATE: May 23, 1998
ATTENTION: Policy, Form and Rate Filing Unit
SUBJECT: Policy, Form and Rate Filing Transmittal Form Effective July 1, 1998
# Purpose
In order to enhance the timeliness, efficiency and record keeping capabilities of our policy, form and rate filing system, the North Dakota Department of Insurance is implementing two significant changes. First, the Department is implementing a new computerized system for the recording of policy, form and rate filings. Secondly, the Department is fully functional as a participant in the State Electronic Rate and Form Filing System (SERFF).
Contained within this bulletin is a new filing transmittal form to be used by all companies when submitting a policy, form or rate filing to the Department. The form is designed to capture critical information in such a way that the Department system and the SERFF system are mutually compatible. Also contained in the bulletin are the filing requirements for each general type of filing. Finally, any special state required filing forms unique to certain filings are included as addendums.
# Scope
The information provided in this bulletin pertains to all licensed companies filing policy, form and rate filings with the Department. The filing transmittal form is to be used on all filings submitted to the Department in paper format. Those companies submitting filings in electronic format via SERFF will find the data fields built into the SERFF system capture the same critical information found on the transmittal form.
600 EAST BOULEVARD ā¢ BISMARCK, ND 58505 ā¢ (701) 328-2440
Consumer Hotline: 1-800-247-0560
Relay North Dakota 1-800-366-6888 (TTY)
Bulletin 98-1
May 23, 1998
Page Two
### Filing Transmittal Form
er format. Those companies submitting filings in electronic format via SERFF will find the data fields built into the SERFF system capture the same critical information found on the transmittal form.
600 EAST BOULEVARD ā¢ BISMARCK, ND 58505 ā¢ (701) 328-2440
Consumer Hotline: 1-800-247-0560
Relay North Dakota 1-800-366-6888 (TTY)
Bulletin 98-1
May 23, 1998
Page Two
### Filing Transmittal Form
The new Policy, Form and Rate Filing Transmittal Form ND1000 is attached and replaces any previous filing transmittal form. The transmittal form is intended for use with all (other than SERFF) policy, form and rate filing submissions to the Department. The back of the transmittal form contains a list of descriptions and definitions to aid companies in completing the transmittal form. A separate Attachment #1 is included which provides a list of types of insurance (TOI) and sub types of insurance (Sub TOI) to use as a guide in completing those specific entries on the transmittal form.
### Effective Date
All companies should begin using the new transmittal form upon receipt of this bulletin.
Effective July 1, 1998 the Department will not accept filings without a properly completed transmittal form attached. A noncompliant filing will be returned to the company in its entirety (including any retaliatory fee) at the company's expense and without review by the Department.
### General Filing Requirements Applicable to All Filings
All filings submitted in a paper format should contain the following:
- A completed North Dakota - Policy, Form and Rate Filing Transmittal Form ND1000. This should be the top document of the filing packet.
- The appropriate retaliatory filing fee. This should be the second item of the filing packet.
- A cover letter with one copy for return to the company.
- A stamped return envelope with which to return the company's copy.
- Addendums and materials as necessary to describe, document and support the filing.
All electronic filings submitted via SERFF should contain the following:
the filing packet.
- The appropriate retaliatory filing fee. This should be the second item of the filing packet.
- A cover letter with one copy for return to the company.
- A stamped return envelope with which to return the company's copy.
- Addendums and materials as necessary to describe, document and support the filing.
All electronic filings submitted via SERFF should contain the following:
- Addendums, components and materials as necessary to describe, document and support the filing.
Bulletin 98-1
May 23, 1998
Page Three
- A reference to the check number being sent with the appropriate retaliatory fee. (Note: Immediately upon sending the electronic filing, mail the appropriate retaliatory fee to the Department of Insurance. SERFF Retaliatory Filing Fee Form ND2000 should be attached to the check. The form contains the appropriate identifying information to facilitate receipt and processing.)
In addition to the above general requirements applicable to all filings, there are specific requirements for certain categories of insurance as follows:
### Property and Casualty - Policy/Form Filing Requirements
The policy/form requirements apply to both paper and electronic formats.
- A complete description of the form to include the purpose of the form, whether the form is new or a revision and whether the form broadens or restricts coverage.
- A list of the forms which includes the company name, form title, number and edition date.
- A description of the impact of any form revision relative to coverage and rate. Side by side comparisons, strikeout mock ups, or detailed narratives are preferred.
- A statement indicating whether any State Amendatory applies to the policy/form and whether one has previously been filed for use with that form.
- A copy of the policy/form (if they are not being filed by reference only), draft or mock up versions are acceptable.
### Property and Casualty - Rate/Rule Filing Requirements
The rule requirements apply to both paper and electronic formats.
eferred.
- A statement indicating whether any State Amendatory applies to the policy/form and whether one has previously been filed for use with that form.
- A copy of the policy/form (if they are not being filed by reference only), draft or mock up versions are acceptable.
### Property and Casualty - Rate/Rule Filing Requirements
The rule requirements apply to both paper and electronic formats.
Rate filings (other than Crop Hail):
- Describe the impact of the filing, include the net effect (percent change), number of policies in the state, and the estimated dollar impact to North Dakota policyholders.
Bulletin 98-1
May 23, 1998
Page Four
- A summary of the rate history for the previous five years.
- Countrywide, regional (ND, SD, MT, WY, NE, and IA) and statewide loss experience for the previous five years to include written premium, earned premium, incurred losses, loss adjustment expense, and loss ratio.
- Countrywide, regional and statewide expense exhibits for the previous five years.
- A copy of the rate pages (draft copies are acceptable).
- Loss cost, and consent to rate filings must use the appropriate form - see addendums.
- An explanatory memorandum describing the basis for the filing to include such items as appropriate actuarial memorandum, competitive comparison, underwriting assumptions, etc. The memorandum should contain loss development, trending, credibility, permissible loss ratio, indicated rate level, investment income offset, etc.
Crop Hail rate filing:
- Attach Crop Insurance Rate Filing Form NDPC 200 - see addendums.
- A copy of the rate pages (draft copies are acceptable).
Rule filing
- A complete description of the rule to include the purpose of the rule, whether the rule is new or a revision, and a comparison to the previous rule if it is a revision.
- A description of the impact a revised rule has on coverage or rate with appropriate supporting documentation.
### Property and Casualty Addendums
dendums.
- A copy of the rate pages (draft copies are acceptable).
Rule filing
- A complete description of the rule to include the purpose of the rule, whether the rule is new or a revision, and a comparison to the previous rule if it is a revision.
- A description of the impact a revised rule has on coverage or rate with appropriate supporting documentation.
### Property and Casualty Addendums
The addendums are unique filing forms to be used in specific filings. They are:
- Crop Insurance Rate Filing Form NDPC 200 is used for the annual crop hail insurance loss cost/rate filing.
Bulletin 98-1
May 23, 1998
Page Five
- Insurer Rate Filing - Adoption of Advisory Loss Cost Form NDPC 300 is used for filing company loss cost multipliers to use in conjunction with an advisory organization filed loss cost.
- Consent to Rate Application Form NDPC 400 is used for filing an individual debited rate which exceeds the company's filed manual rate.
### Life and Health - Policy/Form Filing Requirements
The policy/form requirements apply to both paper and electronic formats:
An actuarial memorandum should be included with the filing (if applicable).
- A list of flesch scores and a readability certification should be provided for all forms being filed.
- The filing company is responsible for compliance with specific North Dakota statutory and regulatory requirements. All companies using the SERFF system have direct access to these requirements via the system. Companies filing in paper format can request a hard copy of requirements for specific sub types of insurance (Sub TOI) from the Life and Health Division.
- A reference in the filing cover letter indicating if the filing content is identical to another pending filing for a sister company.
### Life and Health - Rate/Rule Filing Requirements
The rate/rule requirements apply to both paper and electronic formats:
ing in paper format can request a hard copy of requirements for specific sub types of insurance (Sub TOI) from the Life and Health Division.
- A reference in the filing cover letter indicating if the filing content is identical to another pending filing for a sister company.
### Life and Health - Rate/Rule Filing Requirements
The rate/rule requirements apply to both paper and electronic formats:
- An actuarial memorandum is required to explain and justify all rating and underwriting changes.
- A reference in the filing cover letter indicating if the filing content is identical to another pending filing for a sister company.
### State Electronic Rate and Form Filing System
North Dakota is online and operational with the SERFF system. Any company interested in getting online and using the SERFF system to file electronically should contact State/Industry SERFF Consortium, NAIC Controller, 120 West 12th Street, Suite 1100, Kansas City, MO 64105-1925.
Bulletin 98-1
May 23, 1998
Page Six
## Previous Bulletins
Effective May 23, 1998, this bulletin supersedes the following Department bulletins:
Bulletin 87-5 Consent to Rate Guidelines
Bulletin 88-4 Filing Transmittal Form No. NDPC-100 (6/88)
Bulletin 88-6 Revision of Filing Transmittal Form
Effective January 1, 1999 this bulletin supersedes the following Department bulletin:
Bulletin 97-3 Marketing of Crop Hail Insurance in ND 1998
GP/cm
# NORTH DAKOTA DEPARTMENT OF INSURANCE
# Policy, Form, and Rate Filing Transmittal Form ND 1000
SFN 51679 (5/98)
nt to Rate Guidelines
Bulletin 88-4 Filing Transmittal Form No. NDPC-100 (6/88)
Bulletin 88-6 Revision of Filing Transmittal Form
Effective January 1, 1999 this bulletin supersedes the following Department bulletin:
Bulletin 97-3 Marketing of Crop Hail Insurance in ND 1998
GP/cm
# NORTH DAKOTA DEPARTMENT OF INSURANCE
# Policy, Form, and Rate Filing Transmittal Form ND 1000
SFN 51679 (5/98)
| | | | Date |
| --- | --- | --- | --- |
| Insurance Company Name [attach separate page if companies exceed spaces] | | | Cocode/FEIN |
| | | | |
| | | | |
| | | | |
| | | | |
| Contact Name | | Consulting Firm/Company Name | |
| Contact Address | | | |
| Contact Telephone Number | | Contact Fax Number | |
| Type of Insurance (General) | | Subtype of Insurance (Product Type) | |
| Filing Type (Form, Rule, Rate, Advertisement) | | Filing Action (Initial, Resubmission, Amendment) | |
| Filing Description (Include Form Nos.) [attach separate page if this space is not enough] | | | |
| Company Filing No. | | | |
| Product Name (Marketing Program) | | | |
| Project Name (Company Optional) | | | |
| State(s) of Domicile | Required Retaliatory Fee Amt. | Check Number | Date of Check |
| States Filed In | | | |
| States Approved In | | | |
| Addendum Checklist Crop Insurance Rate Forms Insurer Rate Filing - Adoption of Loss Cost Forms Consent to Rate Forms | | | |
# **Definitions and descriptions of fields on Policy, Form and Rate Filing Transmittal Form ND1000**
Date - The date of the filing , should match the date of the filing letter.
Insurance Company Name - The full insurance company name(s). If the number of companies exceeds the number of lines attach a separate page with the company name and cocode/FEIN.
Cocode/FEIN - The NAIC company code number or federal identification number.
Contact Name - The individual to contact if there are any questions on the filing.
of the filing , should match the date of the filing letter.
Insurance Company Name - The full insurance company name(s). If the number of companies exceeds the number of lines attach a separate page with the company name and cocode/FEIN.
Cocode/FEIN - The NAIC company code number or federal identification number.
Contact Name - The individual to contact if there are any questions on the filing.
Consultant Firm/Company Name - The name of the entity filing on behalf of the company if other than the company.
Contact Address - The address of the contact person to use for any correspondence.
Contact Phone # - The phone of the contact person.
Contact FAX # - The FAX number of the contact person.
Type of Insurance (General) - The general type of insurance applicable to the filing refer to the attachment with the list of types and subtypes of insurance.
Sub type of insurance (Product type) - The specific sub type of insurance or product type applicable to the filing refer to the attachment with the list of types and subtypes of insurance.
Filing type (Form, Rate, Rule, Advertisement) - Select the type of filing, it may be combination of these.
Filing action (Initial, resubmission, amendment) - Initial is a new or original filing, resubmission is a resubmission of a previously disapproved filing, and amendment is a revision or subsequent change to a previously filed and approved filing.
Filing Description (include form #'s) - General description of the filing content, include form numbers where applicable. If there is insufficient space attach a separate page.
Company filing number - The companies internal filing number or identifier (optional).
Product Name (Marketing Program) - The companies unique program name (optional).
Project Name (Company optional) - The companies in house project name (optional).
State(s) of domicile - State of domicile for each company.
Required Retaliatory Fee Amount - Retaliatory fee required by the domiciliary state.
.
Company filing number - The companies internal filing number or identifier (optional).
Product Name (Marketing Program) - The companies unique program name (optional).
Project Name (Company optional) - The companies in house project name (optional).
State(s) of domicile - State of domicile for each company.
Required Retaliatory Fee Amount - Retaliatory fee required by the domiciliary state.
Check Number - Number of the check with the retaliatory fee.
Date of Check - Date of the retaliatory fee check.
States filed in - List of states you have made this filing in.
States approved in - List of states which have approved this filing.
Addendum checklist - Check if any of these addendums are attached to the filing.
# Attachment #1- May 1998
Type of Insurance/TOI and related products or Sub Types of Insurance (Sub TOI) for use with Policy, Form and Rate Filing Transmittal Form ND1000
# Credit Life & Health
Credit disability
Credit life
Credit multi-line
Family leave
Involuntary unemployment
Non-designated
# Life & Annuity
Current assumption whole life
Deferred annuity
GIC/pension plan
annuity/institutional investment
Graded or indeterminate
premium whole life
Immediate annuity
Interest indexed annuity
Interest indexed life
Structured settlement annuity
Term life
Universal life
Viatical settlement
Whole life
Non-designated
# Variable Life & Annuity
Variable deferred annuity
Variable immediate annuity
Variable life
Non-designated
# Life/Annuity/Accident & Health
Association/Employer multiline
Non-designated
# Accident & Health
Accident
Accidental death/or
dismemberment
Blanket accident/sickness
Champus supplement
Critical illness
Dental
Disability income-long term
Disability income-short term
Excess loss
HIV indemnity
Home health care
Hospital indemnity
Hospital/surgical/medical expense
Intensive care
Long term care
Major medical
Medicare supplement
Non-blanket accident/sickness
Organ & tissue transplant
Prescription drug
Specified disease
Vision
nket accident/sickness
Champus supplement
Critical illness
Dental
Disability income-long term
Disability income-short term
Excess loss
HIV indemnity
Home health care
Hospital indemnity
Hospital/surgical/medical expense
Intensive care
Long term care
Major medical
Medicare supplement
Non-blanket accident/sickness
Organ & tissue transplant
Prescription drug
Specified disease
Vision
Non-designated
# Property
Aircraft cargo
Aircraft hull
Allied lines
Auto-commercial physical damage
Auto-private passenger physical damage
Boiler and machinery
Commercial fire and allied lines
Commercial multi-peril
Commercial property
Credit
Credit card
Credit property
Crime
Crop- federal
Crop- hail
1
Crop- supplements
Dwelling
Earthquake
Fire
Flood
Force placed
Glass
Inland marine-commercial
Inland marine-personal
Legal expense
Lenders collateral
Livestock
Mortgage guarantee
Ocean Marine
Pet
Prepaid legal service
Rain
Theft
Title
Vandalism
Vendors single interest
Non-designated
# Casualty
Aircraft liability
Asbestos abatement
Auto-commercial liability
Auto-private passenger liability
Auto warranty
Bonds
Contractual liability
Directors and officers
Employers liability
Environmental impairment
Errors and omissions
Excess/umbrella-commercial
Excess/umbrella-personal
Fidelity
General liability
Home warranty
Legal malpractice
Liquor/dram shop liability
Managed care contracts
Medical malpractice
Personal liability
Pollution liability
Product liability
Products and completed
operations
Professional liability
Ransom/extortion
Stop loss/stop gap liability
Surety
Non-designated
# Property and Casualty
Aircraft
Auto-commercial
Auto-private passenger
Boatowners
Businessowners
Farmowners
Garagekeepers
Homeowners
Mobilehomeowners
Special multiperil
Tenants
Non-designated
# Property/Casualty/Accident & Health
Association/Employer multiline
Travel
Non-designated
# INSTRUCTIONS:
liability
Ransom/extortion
Stop loss/stop gap liability
Surety
Non-designated
# Property and Casualty
Aircraft
Auto-commercial
Auto-private passenger
Boatowners
Businessowners
Farmowners
Garagekeepers
Homeowners
Mobilehomeowners
Special multiperil
Tenants
Non-designated
# Property/Casualty/Accident & Health
Association/Employer multiline
Travel
Non-designated
# INSTRUCTIONS:
1. Select the appropriate general type
of insurance (TOI) that applies to the
filing.
2. Select the appropriate product or
sub type of insurance (Sub TOI) from
within the general TOI category.
3. Use "non-designated" only when
you can not find the appropriate
product in the existing Sub TOI's
list.
4. If the filing consists of several
products or Sub TOI select one that
predominately describes the filing.
2
# NORTH DAKOTA DEPARTMENT OF INSURANCE
# SERFF Retaliatory Filing Fee Form ND2000
SFN 51680 (5/98)
The attached check(s) is/are payment for the following policy, form and rate filing(s) submitted via the State Electronic Rate and Form Filing system (SERFF).
| Type of Insurance (TOI): |
| --- |
| Check Number: |
| Company Name: |
| SERFF Filing Number: |
| Date of SERFF Filing: |
| Amount of check: |
| Type of Insurance (TOI): |
| --- |
| Check Number: |
| Company Name: |
| SERFF Filing Number: |
| Date of SERFF Filing: |
| Amount of check: |
| Contact person: |
| --- |
| Phone number: |
| Date: |
Mail to:
North Dakota Department of Insurance
SERFF Retaliatory Filing Fee
600 East Boulevard Ave. - Dept. 401
Bismarck, ND 58505-0302
# NORTH DAKOTA DEPARTMENT OF INSURANCE
## Crop Insurance Rate Filing Form NDPC200
### Adoption of Advisory Organization Loss Costs
SFN 51682 (5/98)
Date:
| 1. Insurer Name |
| --- |
| 2. Type of Insurance: |
| 3. Advisory Organization: |
| 4. Advisory Organization Reference Filing Number: |
ce
SERFF Retaliatory Filing Fee
600 East Boulevard Ave. - Dept. 401
Bismarck, ND 58505-0302
# NORTH DAKOTA DEPARTMENT OF INSURANCE
## Crop Insurance Rate Filing Form NDPC200
### Adoption of Advisory Organization Loss Costs
SFN 51682 (5/98)
Date:
| 1. Insurer Name |
| --- |
| 2. Type of Insurance: |
| 3. Advisory Organization: |
| 4. Advisory Organization Reference Filing Number: |
5. 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 loss costs in the captioned Reference Filing.
The insurer's rates will be the combination of the loss costs and the loss cost multipliers.
| 6. A. Rate Change due to Advisory Organization's revised Loss Costs: | % |
| --- | --- |
| B. Rate Change due to Insurer's revised Loss Cost Multiplier: | % |
| C. Total Rate Change: = (1 + A) x (1 + B) - 1 | % |
| D. Proposed Effective date of Rate Change: | |
Crop Insurance Rate Filing Form NDPC200 - Adoption of Advisory Organization Loss Costs
Summary of Supporting Information & Calculation of Company Loss Cost Multiplier
SFN 51682 (5/98) Page 2
Insurer Name:
# 1. DEVELOPMENT OF EXPENSE RATIO
Attach 5 year insurer expense history and any other additional supporting information.
This filing will not be considered unless the completed Expense history form is attached.
| EXPENSE PROVISIONS | Previous | Proposed |
| --- | --- | --- |
| A. Total Production Expense: | | % |
| B. General Expense: | | % |
| C. Loss Adjustment Expense: | | % |
| D. Taxes, Licenses & Fees: | | % |
| E. Underwriting Profit & Contingencies: | | % |
| F. Other (Explain): | | % |
| G. TOTAL: | | % |
# 2. EXPECTED LOSS RATIO:
pleted Expense history form is attached.
| EXPENSE PROVISIONS | Previous | Proposed |
| --- | --- | --- |
| A. Total Production Expense: | | % |
| B. General Expense: | | % |
| C. Loss Adjustment Expense: | | % |
| D. Taxes, Licenses & Fees: | | % |
| E. Underwriting Profit & Contingencies: | | % |
| F. Other (Explain): | | % |
| G. TOTAL: | | % |
# 2. EXPECTED LOSS RATIO:
| A. For Medium Range FALCs: (ELR = 100% - 1 G) (Must not be more than 70%) | | % |
| --- | --- | --- |
| B. For Low Range FALCs:(ELR = 2A - 5%) | | % |
| C. For High Range FALCs:(ERL = 2A + 5%) | | % |
# 3. COMPANY FORMULA LOSS COST MULTIPLIER:
| A. For Medium Range FALCs:(FLCM = 1.00 / 2A) (Must not be less than 1.429) | | |
| --- | --- | --- |
| B. For Low Range FALCs:(FLCM = 1.00 / 2B) | | |
| C. For High Range FALCs:(FLCM = 1.00 / 2C) | | |
Provide detailed explanation and support for any difference between historical and proposed expense provisions.
# 4. CASH DISCOUNT:
%
NORTH DAKOTA DEPARTMENT OF INSURANCE
Crop Insurance Rate Filing Form NDPC200
North Dakota Expense History For Prior Five Years
SFN 51682 (5/98) Page 3
Insurer Name:
NAIC Number:
| YEAR: | | | | | | | | | | | 5 Year Historical Average Percent of Premium |
| --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- |
| | $ Amount | % of Prem | $ Amount | % of Prem | $ Amount | % of Prem | $ Amount | % of Prem | $ Amount | % of Prem | |
| Crop Hail Premiums * | | 100 | | 100 | | 100 | | 100 | | 100 | |
| A) Actual Losses ** B) Production Expense | | | | | | | | | | | |
| C) General Expense | | | | | | | | | | | |
| D) Loss Adjustment Expense | | | | | | | | | | | |
| E) Taxes, Licenses & Fees | | | | | | | | | | | |
| F) Other Expense (Explain) | | | | | | | | | | | |
| G) Profit(Loss) & Contingencies | | | | | | | | | | | |
| H) Total: A through G | | | | | | | | | | | |
| I) Cash Disco
C) General Expense | | | | | | | | | | | |
| D) Loss Adjustment Expense | | | | | | | | | | | |
| E) Taxes, Licenses & Fees | | | | | | | | | | | |
| F) Other Expense (Explain) | | | | | | | | | | | |
| G) Profit(Loss) & Contingencies | | | | | | | | | | | |
| H) Total: A through G | | | | | | | | | | | |
| I) Cash Discount | | | | | | | | | | | |
Person responsible for Filing:
Phone #:
* Includes premium fr Crop Hail and Companion Hail-type policies
** Does not include any Loss Adjustment Expense
Date:
NORTH DAKOTA DEPARTMENT OF INSURANCE
Crop Insurance Rate Filing Form NDPC200
Country Wide Expense History For Prior Five Years
SFN 51682 (5/98) Page 4
Insurer Name:
NAIC Number:
| YEAR: | | | | | | | | | | |
| --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- |
| | $ Amount | % of Prem | $ Amount | % of Prem | $ Amount | % of Prem | $ Amount | % of Prem | $ Amount | % of Prem |
| Crop Hail Premiums * | | 100 | | 100 | | 100 | | 100 | | 100 |
| A) Actual Losses ** | | | | | | | | | | |
| B) Production Expense | | | | | | | | | | |
| C) General Expense | | | | | | | | | | |
| D) Loss Adjustment Expense | | | | | | | | | | |
| E) Taxes, Licenses & Fees | | | | | | | | | | |
| F) Other Expense (Explain) | | | | | | | | | | |
| G) Profit(Loss) & Contingencies | | | | | | | | | | |
| H) Total: A through G | | | | | | | | | | |
Person responsible for Filing:
Phone #:
* Includes premium fr Crop Hail and Companion Hail-type policies
** Does not include any Loss Adjustment Expense
Date:
# NORTH DAKOTA DEPARTMENT OF INSURANCE
# Crop Insurance Rate Filing Form NDPC200
# Supplemental Statistical Information
SFN 51682 (5/98) Page 5
| Insurer Name: |
| --- |
| Year* |
al: A through G | | | | | | | | | | |
Person responsible for Filing:
Phone #:
* Includes premium fr Crop Hail and Companion Hail-type policies
** Does not include any Loss Adjustment Expense
Date:
# NORTH DAKOTA DEPARTMENT OF INSURANCE
# Crop Insurance Rate Filing Form NDPC200
# Supplemental Statistical Information
SFN 51682 (5/98) Page 5
| Insurer Name: |
| --- |
| Year* |
| POLICY TYPE: | MPCI (1) | | MPCI SUPPLEMENTS (2) | |
| --- | --- | --- | --- | --- |
| | $ Amount | % of Prem | $ Amount | % of Prem |
| Premium | | | | |
| Losses | | | | |
| Production Expense | | | | |
| General Expense | | | | |
| Loss Adjustment Expense | | | | |
| Taxes, Licenses & Fees | | | | |
| Other (Explain) | | | | |
| Profit (Loss) & Contingencies | | | | |
MPCI: Federally reinsured/ subsidized MPCI/FCIC Crop
MPCI
Supplements: Add on coverages to the MPCI product, which are subsidized by FCIC.
* Experience should be summarized for most recent crop year.
# NORTH DAKOTA DEPARTMENT OF INSURANCE
## Crop Insurance Rate Filing Form NDPC200
### Premium Distribution by County
SFN 51682 (5/98) Page 6
YEAR*
| COUNTY NUMBER | COUNTY NAME | PREMIUM | COUNTY NUMBER | COUNTY NAME | PREMIUM |
| --- | --- | --- | --- | --- | --- |
| 1 | Adams | | 55 | Mc Lean | |
| 3 | Barnes | | 57 | Mercer | |
| 5 | Benson | | 59 | Morton | |
| 7 | Billings | | 61 | Mountrail | |
| 9 | Bottineau | | 63 | Nelson | |
| 11 | Bowman | | 65 | Oliver | |
| 13 | Burke | | 67 | Pembina | |
| 15 | Burleigh | | 69 | Pierce | |
| 17 | Cass | | 71 | Ramsey | |
| 19 | Cavalier | | 73 | Ransom | |
| 21 | Dickey | | 75 | Renville | |
| 23 | Divide | | 77 | Richland | |
| 25 | Dunn | | 79 | Rolette | |
| 27 | Eddy | | 81 | Sargent | |
| 29 | Emmons | | 83 | Sheridan | |
| 31 | Foster | | 85 | Sioux | |
| 33 | Golden Valley | | 87 | Slope | |
| 35 | Grand Forks | | 89 | Stark | |
| 37 | Grant | | 91 | Steele
amsey | |
| 19 | Cavalier | | 73 | Ransom | |
| 21 | Dickey | | 75 | Renville | |
| 23 | Divide | | 77 | Richland | |
| 25 | Dunn | | 79 | Rolette | |
| 27 | Eddy | | 81 | Sargent | |
| 29 | Emmons | | 83 | Sheridan | |
| 31 | Foster | | 85 | Sioux | |
| 33 | Golden Valley | | 87 | Slope | |
| 35 | Grand Forks | | 89 | Stark | |
| 37 | Grant | | 91 | Steele | |
| 39 | Griggs | | 93 | Stutsman | |
| 41 | Hettinger | | 95 | Towner | |
| 43 | Kidder | | 97 | Traill | |
| 45 | La Moure | | 99 | Walsh | |
| 47 | Logan | | 101 | Ward | |
| 49 | Mc Henry | | 103 | Wells | |
| 51 | Mc Intosh | | 105 | Williams | |
| 53 | Mc Kenzie | | TOTAL ( ALL COUNTIES *) | | |
* Experience should be summarized for most recent crop year.
Total should match premium entry on Page 3 of form NDPC 200 for most recent year.
# NORTH DAKOTA DEPARTMENT OF INSURANCE
# Insurer Rate Filing - Adoption of Advisory Organization
# Prospective Loss Costs Reference Filing Form NDPC300
SFN 51681(5/98)
Date:
| Insurer Name: |
| --- |
| Type of Insurance: |
| --- |
| Advisory Organization: |
| Advisory Organization Reference Filing Number: |
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 a combination of the prospective loss costs and the loss cost multipliers and, if utilized, the expense constants specified in the attachments.
| Rate Change due to Advisory Organization's revised reference filing: | % |
| --- | --- |
| Rate Change due to Insurer's revised Loss Cost Multiplier: | % |
| Total Rate Change: | % |
| Proposed Effective Date of Rate Change: | |
Attach "Summary of Supporting Information Form NDPC300 Page 2"
the loss cost multipliers and, if utilized, the expense constants specified in the attachments.
| Rate Change due to Advisory Organization's revised reference filing: | % |
| --- | --- |
| Rate Change due to Insurer's revised Loss Cost Multiplier: | % |
| Total Rate Change: | % |
| Proposed Effective Date of Rate Change: | |
Attach "Summary of Supporting Information Form NDPC300 Page 2"
Use a separate summary for each insurer-selected loss cost multiplier.
Check one of the following:
ā
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 apply to policies written on or after the effective date of the advisory organization's prospective loss costs.
ā
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.
# NORTH DAKOTA DEPARTMENT OF INSURANCE
# Insurer Rate Filing - Adoption of Advisory Organization Prospective
# Loss Costs Reference Filing Form NDPC300
# Summary of Supporting Information
SFN 51681 (5/98) Page 2
| Insurer Name: | | | |
| --- | --- | --- | --- |
| 1. Line, Subline, Coverage, Territory, Class, etc. combination to which this page applies: | | | |
| 2. Loss Cost Modification: A. The insurer hereby files to adopt the prospective loss costs in the captioned reference filing: CHECK ONE ā Without Modification. ā With the following modification. Cite the nature and percent of modification, and attach supporting data and/or rationale for the modification. | | | |
| | | | |
| | | | |
| B. Loss Cost Modification Expressed as a Factor (see examples below): | | | |
| | Current Modifier: | | Proposed Modifier: |
the captioned reference filing: CHECK ONE ā Without Modification. ā With the following modification. Cite the nature and percent of modification, and attach supporting data and/or rationale for the modification. | | | |
| | | | |
| | | | |
| B. Loss Cost Modification Expressed as a Factor (see examples below): | | | |
| | Current Modifier: | | Proposed Modifier: |
NOTE: IF EXPENSE CONSTANTS ARE UTILIZED, ATTACH "EXPENSE CONSTANT SUPPLEMENT" OR OTHER SUPPORTING INFORMATION. DO NOT COMPLETE ITEMS 3 - 7 BELOW.
| 3. Development of Expected Loss Ratio: An exhibit with supporting expense history must be attached. Five years of expense history is required for Fire insurance. Three years of expense history is required for all other lines. | | |
| --- | --- | --- |
| | Current | Proposed |
| A. Total Production Expense: | % | % |
| B. General Expense: | % | % |
| C. Taxes, Licenses & Fees: | % | % |
| D. Underwriting Profit & Contingencies | % | % |
| E. Other (Explain) | % | % |
| F. Total | % | % |
| 4. Expected Loss Ratio: ELR = 100% - 3F: | % | % |
| 5. Company Formula Loss Cost Multiplier: = (Proposed 2B / Proposed #4): | | |
| 6. Company Selected Loss Cost Multiplier: | | |
| Explain any differences between 5 and 6: | | |
| | | |
| | | |
7. Total Rate level change for the coverages to which this page applies:
%
Example 1: If your company's loss cost modification is -10%, a factor (1.00 - .10) = .90 should be used.
Example 2: If your company's loss cost modification is +15%, a factor (1.00 + .15) = 1.15 should be used.
# NORTH DAKOTA DEPARTMENT OF INSURANCE
## Consent to Rate Application Form NDPC400
SFN 51683 (5/98)
Please file and approve the following rates, which I understand are Excess of those rates otherwise filed with the North Dakota Department of Insurance
| Company Name | NAIC # |
| --- | --- |
| Company Address | |
| | |
| | |
| Company Representative | Date |
POLICY INFORMATION
.
# NORTH DAKOTA DEPARTMENT OF INSURANCE
## Consent to Rate Application Form NDPC400
SFN 51683 (5/98)
Please file and approve the following rates, which I understand are Excess of those rates otherwise filed with the North Dakota Department of Insurance
| Company Name | NAIC # |
| --- | --- |
| Company Address | |
| | |
| | |
| Company Representative | Date |
POLICY INFORMATION
| Type of Business | |
| --- | --- |
| Location(s) of Risk | |
| | |
| | |
| Description of Coverage | |
| | |
| | |
| Policy Number | Effective Dates/Term of Policy |
| Policy Limits | |
| Filed Manual Premium | Proposed Premium |
APPLICANT INFORMATION
| I am agreeable to paying this premium because of the following reason(s) | |
| --- | --- |
| | |
| | |
| Name of Insured (Applicant) | |
| Mailing Addresss | |
| | |
| | |
| Signature of Named Insured | Date |