INDIVIDUAL AND SMALL GROUP FILING SUMMARY
| Carrier Name | |
| Address | |
| |
| |
| Carrier Identification Number | |
| |
| Rate Renewal Period: | From | | To | |
| Date Submitted: | |
| |
Proposed Rate Summary
| Current community rate | per month |
| Proposed community rate | per month |
| Percentage change | % |
| Portion of carrier's total enrollment affected | % |
| Portion of carrier's total premium revenue affected | % |
| |
Components of Proposed Community Rate
| Dollars Per Month | % ofTotal |
| a) Claims | | |
| b) Expenses | | |
| c) Contribution to surplus, contingency charges, or risk charges | | |
| d) Investment earnings | | |
| e) Total (a + b + c - d) | | |
Summary of Pooled Experience
| Experience Period | First Prior Period | Second PriorPeriod |
| From To | From To | From To |
| Member Months | | | |
| Earned Premium | | | |
| Paid Claims | | | |
| Beginning Claim Reserve | | | |
| Ending Claim Reserve | | | |
| Incurred Claims | | | |
| Expenses | | | |
| Gain/Loss | | | |
| Loss Ratio Percentage | | | |
General Information
| Type of Service | Annual TrendAssumed | Portion of Claim Dollars |
| Hospital | % | % |
| Professional | % | % |
| Prescription Drugs | % | % |
| Dental | % | % |
| Other | % | % |
| 2. List the effective date and the rate of increase for all rate changes in the past three rate periods. |
| 1) | | 2) | | 3) | |
| Date | % | | Date | % | | Date | % |
| 3. Since the previous filing, have any changes been made to the factors or methodology for adjusting base rates? |
| Geographic Area | □ Yes | □ No |
| Family Size | □ Yes | □ No |
| Age | □ Yes | □ No |
| Wellness Activities | □ Yes | □ No |
| Other (specify) | □ Yes | □ No |
| 4. Attach a table showing the base rate for each plan affected by this filing. |
| 5. Attach comments or additional information. |
| 6. Preparer's Information |
| Name: | |
| Title: | |
| Telephone Number: | |
[Statutory Authority: RCW 48.02.060, 48.44.050, 48.46.200, and 2016 c 156. WSR 16-23-019 (Matter No. R 2016-06), recodified as § 284-43-6660, filed 11/4/16, effective 12/5/16. WSR 16-01-081, recodified as § 284-43-6160, filed 12/14/15, effective 12/14/15. Statutory Authority: RCW 48.02.060, 48.18.110, 48.44.020, 48.44.050, 48.46.060, 48.46.200. WSR 08-20-071 (Matter No. R 2008-08), § 284-43-945, filed 9/25/08, effective 10/26/08. Statutory Authority: RCW 48.02.060, 48.44.050, and 48.46.200. WSR 05-07-006 (Matter No. R 2004-05), § 284-43-945, filed 3/3/05, effective 4/3/05. 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 and 48.46.066. WSR 98-04-011 (Matter No. R 97-2), § 284-43-945, filed 1/23/98, effective 3/1/98.]