1. A. Reference Filing Adoption Form. State of Maryland Insurer Rate Filing Adoption of Rating Organization Prospective Loss Costs Summary of Supporting Information Form Calculation of Company Loss Cost Multiplier

   	Date _________________
   Space Reserved for Insurance Department Use	Insurer Rate Filing Adoption of Rating Organization Prospective Loss Costs Reference Filing Adoption Form State of Maryland
   1. Insurer Name	____________________________
   Address	____________________________
   	____________________________
   	____________________________
   	____________________________

   Person Responsible for Filing	____________________________
   Title ___________________________	Telephone # __________________
   2. Insurer NAIC #	____________________________
   3. Line of Insurance	____________________________
   4. Rating Organization	____________________________
   5. Rating Organization Reference Filing #	____________________________
   6. The above insurer hereby declares that it is a member, subscriber or service purchaser of the named rating 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.
   7. Proposed Rate Level
   Change ____________ %	Effective Date _________________
   8. Prior Rate Level
   Change ____________ %	Effective Date _________________
   9. Attach “Summary of Supporting Information Form” (Use a separate Summary for each insurer-selected loss cost multiplier.)
   10. 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 rating organization's prospective loss costs for this line of insurance. The insurer's rates will be the combination of the rating 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 effective on or after the effective date of the rating organization's prospective loss costs. This authorization is effective until disapproved by the Commissioner, or amended or withdrawn by the insurer.
   ( ) The insurer hereby files to have its loss cost multipliers and, if utilized, expense constants be applicable only to the above Rating Organization Reference Filing.
   B. Summary of Supporting Information Form.
   Insurer Name: ____________________	Date: _______________________
   NAIC Number: ___________________

2. 1. Line, Subline, Coverage, Territory, Class, etc. combination to which this page applies: ________________________________________________________

3. 2. Loss Cost Modification:

   1. 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.) ________________________________________________________ ________________________________________________________
   2. B. LOSS COST MODIFICATION Expressed as a Factor: _______ (See examples below.) NOTE: If expense constants are utilized, attach “Expense Constant Supplement”, §C, below, or other supporting information. Do not complete items 3—7, below.

4. 3. Development of Expected Loss Ratio. (Attach exhibit detailing insurer expense data and/or other supporting information.) State of Maryland Expense Constant Supplement Calculation of Company Loss Cost Multiplier With Expense Constants

   	Selected Provisions
   A. Total Production Expense	________________ %
   B. General Expense	________________ %
   C. Taxes, Licenses, and Fees	________________ %
   D. Underwriting Profit and Contingencies	________________ %
   E. Other (explain)	________________ %
   F. TOTAL	________________ %
   4A. Expected Loss Ratio: ELR =
   100% - 3F =	________________ %
   4B. ELR in decimal form =	________________
   5. Company Formula Loss Cost
   Multiplier: (2B/4B)=	________________
   6. Company Selected Loss Cost
   Multiplier =	________________
   Explain any differences between 5 and 6:
   ________________________________________________ ________________________________________________
   7. Rate level change for the coverages to
   which this page applies:	________________ %
   ________________________________________________ ________________________________________________
   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.
   C. Expense Constant Supplement Form.
   Insurer Name: _____________________	Date: ____________
   NAIC Number: __________________________________________

5. 1. Development of Expected Loss Ratio. (Attach exhibit detailing insurer expense data and/or other supporting information.

   	Overall	Selected Provisions Variable	Fixed
   A. Total Production Expense	_______	________	________
   B. General Expense	_______	________	________
   C. Taxes, Licenses, and Fees	_______	________	________
   D. Underwriting Profit and Contingencies	_______	________	________
   E. Other (explain)	_______	________	________
   F. TOTAL	_______	________	________
   2.A. Expected Loss Ratio: ELR = 100% - Overall 1F =	_______
   B. ELR expressed in decimal form =	_______
   C. Variable Expected Loss Ratio VELR = 100% - Variable 1F =		________
   D. VELR in decimal form =		________

   3. Formula Expense Constant: ((1.00+2B) - (1.00+2D)) x Average Underlying Loss Cost = ________ Formula Variable Loss Cost Multiplier: (2B+2D) = ________

   4. Selected Expense Constant = ________ Selected Variable Loss Cost Multiplier ________

   5. Explain any differences between 3 and 4:

   _____________________________________________ _____________________________________________

   6. Rate level change for the coverages to which this page applies: _______%

Authority: Insurance Article, §§2-109, 11-206, and 11-218, Annotated Code of Maryland

Effective date: July 12, 1927

Amended effective May 1, 1968

Chapter, Industrial Life, Health, and Accident Insurance Agents—Employment on Debit on Which He Previously Worked, repealed effective February 22, 1988 (15:4 Md. R. 472)

Regulations .01—.08, Property, Casualty, Surety, and Marine Rating, and Supplementary Information Filings, adopted as an emergency provision effective July 1, 1990 (17:15 Md. R. 1845); emergency status expired October 31, 1990; adopted permanently effective November 12, 1990 (17:22 Md. R. 2655)

Regulation .08 amended effective March 25, 1996 (23:6 Md. R. 475)

Chapter recodified from COMAR 09.30.21 to COMAR 31.07.01 effective September 7, 1998 (25:18 Md. R. 1439)

Regulation .01 amended effective November 17, 2008 (35:23 Md. R. 2017)

Regulation .02 amended effective November 17, 2008 (35:23 Md. R. 2017)

Regulation .03B amended effective November 17, 2008 (35:23 Md. R. 2017)

Regulation .04A amended effective November 17, 2008 (35:23 Md. R. 2017)

Regulation .05A amended effective November 17, 2008 (35:23 Md. R. 2017)

Regulation .06 amended effective November 17, 2008 (35:23 Md. R. 2017)