(a) The commissioner, upon the commissioner’s own initiative or upon request by an insurer, shall waive any requirement of this part if such waiver does not contradict the objective or intent of the rule and:

1. (1) Applying the rule provision would cause confusion or would be misleading to consumers;
2. (2) The rule provision is in whole or in part inapplicable to the given circumstances;
3. (3) There are specific circumstances unique to the situation such that strict compliance with the rule would be onerous without promoting the objective or intent of the rule provision; or
4. (4) Any other similar extenuating circumstances exist such that application of an alternative standard or procedure better promotes the objective or intent of the rule provision.

(d) A request for a waiver shall specify the basis for the waiver and proposed alternative, if any.

1. 1. INSURER NAME _____________________________________________________________________

   ADDRESS ____________________________________________________________

   ______________________________________________________________________

   ______________________________________________________________________

   PERSON RESPONSIBLE FOR FILING ________________________________________________

   TITLE ______________________TELEPHONE # ________________________________________

2. 2. NAIC COMPANY # ______________________ NAIC GROUP #_____________________________
3. 3. LINE OF INSURANCE _________________________________________________________________
4. 4. ADVISORY ORGANIZATION ___________________________________________________________
5. 5. ADVISORY ORGANIZATION REFERENCE FILING # _______________________________________

6. 6. 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.

7. 7. PROPOSED RATE LEVEL CHANGE ____% EFFECTIVE DATE ___________________
8. 8. PRIOR RATE LEVEL CHANGE ____% EFFECTIVE DATE_________________________

9. 9. 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 amended or withdrawn by the insurer.

   ______The insurer hereby files to have its loss costs multipliers and, if utilized, expense constants be applicable only to the above advisory organization reference filing.

   I. CALCULATION OF COMPANY LOSS COST MULTIPLIER WITHOUT EXPENSE CONSTANT

10. 1. Line, subline, coverage, territory, class, etc. combination to which this page applies _____________

    __________________________________________________________________________________

11. 2. Loss Cost Modification:

    A. The insurer hereby files to adopt the prospective loss costs in the captioned reference filing:

    Without modification. (factor=1.000)

    With the following modification: _________%

    (Cite the nature of the modification, and attached supporting data and rationale.)

    _________________________________________________________________________

    _________________________________________________________________________

    B. Loss Cost Modification Expressed as a Factor: __________

12. 3. 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 & Fees ______________% (+)

    D. Underwriting Profit & Contingencies ______________% (+)

    E. Investment Income ______________% (-)

    F. Other (explain) ______________% (+)

    G. TOTAL ______________%

13. 4. A. Expected Loss Ratio: ELR:ELR=100%- 3G ______________%

    B. ELR in decimal form = _____________

14. 5. Calculated Loss Cost Multiplier (1.00/4B)= ______________%

15. 6. Company Selected Loss Cost Multiplier = ______________

    Any difference between 5 and 6 should be explained on line 2.

16. 7. Rate level change for the coverages to which

    this page applies. _____________%

    II. CALCULATION OF COMPANY LOSS COST MULTIPLIER WITH EXPENSE CONSTANTS

17. 1. Line, subline, coverage, territory, class, etc. combination to which this page applies __________

    _______________________________________________________________________________

18. 2. Loss Cost Modification:

    A. The insurer hereby files to adopt the prospective loss costs in the captioned reference filing:

    Without modification. (factor=1.000)

    With the following modification: _________%

    (Cite the nature of the modification, and attached supporting data and rationale.)

    ____________________________________________________________________________

    ____________________________________________________________________________

    B. Loss Cost Modification Expressed as a Factor: ____________________________________

19. 3. Development of Expected Loss Ratio. (Attach exhibit detailing insurer expense data and/or other supporting information, including an explanation of the split between fixed and variable expenses.)

    Selected Provisions

    Overall Variable Fixed

    A. Total Production Expense _______ _______ ________(+)

    B. General Expense _______ _______ ________(+)

    C. Taxes, Licenses & Fees _______ _______ ________(+)

    D. Underwriting Profit & Contingencies _______ _______ ________(+)

    E. Investment Income _______ _______ ________(-)

    F. Other (explain) _______ ______ ________(+)

    G. TOTAL _______ _______ _________

20. 4. A. Expected Loss Ratio (ELR): 100% - Overall 3G. = _________

    B. ELR in decimal form = _________

    C. Variable Expected Loss Ratio (VELR): 100%-Variable 3.G = _________

    D. VELR in decimal form = _________

21. 5. A. Formula Expense Constant

    (1.00/4B-1.00/4D) x Average Underlying Loss Cost = _________

    B. Formula Variable Loss Cost Multiplier: (I.2.B ÷ III.2.D) = _________

    C. Selected Expense Constant = _________

22. 6. A. Formula Variable Loss Cost Multiplier: (1.00/4D)= _________

    B. Selected Variable Loss Cost Multiplier (2B/6A) = _________

23. 7. Explain any differences between 5A and 5B.

    Any difference between 6A and 6B should be explained on line ________________________________________________________________________________

24. 8. Rate level change for the coverages to which this page applies: ________%

    APPENDIX B

    Rule

    Statute

    Ins 2801.01

    RSA 412:16, II, III, VI; RSA 412:25; RSA 412:43

    Ins 2801.02

    RSA 412:20

    Ins 2801.03

    RSA 412:15; RSA 412:16; RSA 412:19; RSA 412:23; RSA 412:25

    Ins 2801.04

    RSA 412:15; RSA 412:16

    Ins 2801.05

    RSA 412:16

    Ins 2801.06

    RSA 412:16

    Ins 2801.07

    RSA 400-A:15, I; RSA 541-A:22, IV

Source. #14510, eff 2-7-26, EXPIRES: 2-7-36

APPENDIX A

FORM RFF-1

Date:

PROSPECTIVE LOSS COSTS REFERENCE

FILING ADOPTION FORM