Wash. Admin. Code § 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

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 GroupContract		□ 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	%

Summary of Contract Experience

	Experience Period	First Prior Period	Second PriorPeriod
	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:

[Statutory Authority: RCW 48.02.060, 48.44.050, 48.46.200, 48.44.020 (2)(d), 48.44.022, 48.44.023, 48.46.060 (3)(d) and (5), 48.46.064, 48.46.066, and 2015 c 19. WSR 16-03-018 (Matter No. R 2015-04), § 284-43-6540, filed 1/8/16, effective 1/8/16.]