WAC 284-43-6540. Summary for group contract filings other than small group contract filings

Groups Other Than Small Groups Filing Summary Carrier Name Address Contract Holder/Pool Category and Name (Check One Box) □ Single Employer Group: Employer Name: □ Multiemployer other than Association/Trust Groups Group Pool Name: □ Association/Trust Groups Association/Trust Group Name: Contract Form Number Rate Form Number (if different from Contract Form Number) Product Name Carrier Name Address Contract Holder/Pool Category and Name (Check One Box) □ Single Employer Group: Employer Name: □ Multiemployer other than Association/Trust Groups Group Pool Name: □ Association/Trust Groups Association/Trust Group Name: Contract Form Number Rate Form Number (if different from Contract Form Number) Product Name If additional space is required to list the contract/rate form number and product name, attach a separate sheet. Rate Renewal Period: From: To: Date Submitted: _____ Type of Filing (Check One Box) □ New Group Contract □ Revision of Existing Group Contract Rate Renewal Period: From: To: Date Submitted: _____ Type of Filing (Check One Box) □ New Group Contract □ Revision of Existing Group Contract Proposed Rate Schedules: Attach a separate sheet to list all proposed tier rates. Rate Summary 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 % 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 % Summary of Contract Experience 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 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: Attach comments or additional information. Preparer's Information Name: Title: Telephone Number: