WAC 284-55-210. Form of medicare supplement loss ratio experience

The following form of medicare supplement loss ratio experience shall be used by all insurers: MEDICARE SUPPLEMENT LOSS RATIO EXPERIENCE (SUMMARIZED BY POLICY YEAR) Experience reported for January 1 to December 31 of 19 To be filed on or before June 30 of the Address (City, State, and Zip Code) NAIC Group Code NAIC Company Code CIC Code National Experience Form No. No. of Contracts in Force Policy Duration Incurred Losses Earned Premiums Loss Ratio Unearned Premium Reserve Policy Reserves Claim Reserves Washington Experience Form No. No. of Contracts in Force Policy Duration Incurred Losses Earned Premiums Loss Ratio Unearned Premium Reserve Policy Reserves Claim Reserves I hereby certify that I have supervised the preparation of this experience exhibit, that it is complete and accurate to the best of my knowledge, and it is in compliance with RCW 48-66-150 , and WAC 284-55-115 , and WAC 284-55-150 . Signature of Officer Date Name and Title of Officer Prepared by Phone Number Experience reported for January 1 to December 31 of 19 To be filed on or before June 30 of the Address (City, State, and Zip Code) NAIC Group Code NAIC Company Code CIC Code National Experience Form No. No. of Contracts in Force Policy Duration Incurred Losses Earned Premiums Loss Ratio Unearned Premium Reserve Policy Reserves Claim Reserves Washington Experience Form No. No. of Contracts in Force Policy Duration Incurred Losses Earned Premiums Loss Ratio Unearned Premium Reserve Policy Reserves Claim Reserves I hereby certify that I have supervised the preparation of this experience exhibit, that it is complete and accurate to the best of my knowledge, and it is in compliance with RCW 48-66-150 , and WAC 284-55-115 , and WAC 284-55-150 . Signature of Officer Date Name and Title of Officer Prepared by Phone Number