Wash. Admin. Code § 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. ofContractsin Force	PolicyDuration	IncurredLosses	EarnedPremiums	Loss Ratio	UnearnedPremiumReserve	PolicyReserves	ClaimReserves

Washington Experience

Form No.	No. ofContractsin Force	PolicyDuration	IncurredLosses	EarnedPremiums	Loss Ratio	UnearnedPremiumReserve	PolicyReserves	ClaimReserves

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

[Statutory Authority: RCW 48.02.060 (3)(a) and 48.66.050. WSR 89-11-096 (Order R 89-7), § 284-55-210, filed 5/24/89.]