Fillable Printable Transmittal Checklist For Life/Health Rate And Form Filings

Transmittal Checklist For Life/Health Rate And Form Filings

Texas Department of Insurance | www.tdi.texas.gov

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TEXAS DEPARTMENT OF INSURANCE

(512) 676-6888 | F: (512) 490-1017 | (800) 578-4677 | TDI.texas.gov | @TexasTDI

333 Guadalupe, Austin, Texas 78701 PO Box 149104, Austin, Texas 78714-9104

Regulatory Policy Division - Life/Health and HMO Intake Team (106-1E)

Transmittal Checklist for Life/Health Rate and Form Filings

Insurance Company Name

Address

City, State, Zip Code

Contact Person

Phone Number Fax Number

Email Address

If the contact person is someone other than the company, please attach a letter of authorization.

1. Select Individual or Group (Please fill in the Chapter 1131 section for Life Groups or Chapter 1251

section for

Accident and Health Groups. See the Appendix on page 6.)

Individual Group Chapter 1131

Section

Chapter 1251

Section

2. Select the product being submitted

Accident and Health Life, Accident and Health EPO - Exclusive Provider Plan

Life

Long Term Care Life Settlement

Annuity

Medicare Supplement Nonprofit Prepaid Legal

Credit

Medicare SELECT

Business Change (Name Change, Merger)

B. Select as applicable

Audit Revisions Consumer Choice Health Benefit Plans

Prepaid Funeral

Rate Filing

Insert Page(s)

Written Plan Description EPO and PPO

Outline of Coverage

Matrix

Point of Service

Select one:

Other

Please describe

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3. Complete the following regarding confidentiality:

SERFF Filings. It is the sole responsibility of the company for setting the Public Access to designate filings

as Confidential in SERFF. TDI will not perform this function for the filer on SERFF filings. Please refer to

the SERFF Filing Rules General Instructions for Texas regarding Public Access.

Paper Filings. Complete as applicable.

Entire Filing

Partial Filing

Note which documents

No Confidential Information

4. Complete the following:

A. List all form numbers submitted with this filing and give a brief description of the purpose coverage for

each form. Please continue the list of form numbers on a separate page. Please refer to 28 TAC §3.2

and

§3.1740(d)(3)-(6).

Form number and brief description

The form(s) will be used on a general use basis.

The form(s) will only be used with the form(s) included in this filing.

The form(s) will only be used with the following previously approved form(s). Complete below.

The form(s) will only be used with the following previously exempt form(s). Complete below.

Form Number and SERFF Filing Number

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5. Forms are submitted as:

Chapter 1701.054 (File for Review and Approval) Complete 7.B.

Chapter 1701.005 (Exempt) Complete 7.B.

Chapter 1701.052 (File and Use) Complete 7.A.

Chapter 1251.054 and Chapters 1131, 1151, and 1153 (Credit Insurance) Complete 7.B.

Chapter 260 and Section 961.252, TIC; and 28 TAC Chapter 23 (Nonprofit Prepaid Legal) Complete 7.B.

Chapter 1111A (Life Settlement) Complete 7.B.

28 TAC 3.1740(f)(1) (File for Review and Approval) Complete 7.A or 7.B. as applicable.

28 TAC §3.5(b)(1) (Informational) Complete 7.B.

6. Rate Filings:

Initial Subsequent Annual Informational

Increase

Percentage

Decrease

Percentage

Form Number and SERFF Filing Number

ATTENTION: Fees remitted for rejected filings will not be refunded or applied to future submissions.

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7. A. Please select Specific and File and Use

SPECIFIC: The certification is on behalf of and is binding to:

Company Name

The duly authorized agent has reviewed and is familiar with all applicable statutes and regulations of this

state and of the United States, and that to the best of his or her knowledge, information, and belief that the

filed form(s) complies in all respects with the applicable statutes and regulations.

FILE AND USE - CHAPTER 1701.052, TIC and 28 TAC §3.5(a)(2) or Chapter 1111A, TIC and 28 TAC

3.1740(f)(2) - It is our intent to use the filed form(s) upon receipt of such filing by the department. I

certify that no corrections to the form(s) have been previously requested by the department. I

certify that the form(s) has not been previously disapproved.

7. B. For all other form filings, please select General and the appropriate section:

GENERAL: The certification is on behalf of and is binding to:

Company Name

The duly authorized agent has reviewed the filing and to the best of his or her knowledge, information, and

belief that the filed form(s) comply with the applicable statutes and regulations of this state.

REVIEW AND APPROVAL - 28 TAC §3.5(a)(1)

EXEMPT - 28 TAC §3.5(a)(3) I certify that the form(s) filed: is not deceptive or misleading and does not

contain exceptions or conditions that unreasonably or deceptively affect the risk purported to be

assumed in the general coverages of the policy; meets the criteria specified in §3.4004; does not contain

any new, uncommon, or unusual provisions, conditions, or concepts as provided in §3.4006; and will be

discontinued in the event of future law or rule changes that would prohibit the use of such form(s). I

certify that the submitting company has had a certificate of authority to do such business in Texas for a

period not less than two years as required by §3.4007.

INFORMATIONAL - 28 TAC §3.5(b)(1) Filing is submitted for informational purposes only and is not

subject to approval.

SUBSTANTIALLY SIMILAR TO A PREVIOUSLY APPROVED FORM - 28 TAC §3.5(b)(2) or 28 TAC 3.1740(h)

(3) Filing is substantially similar to a form that was previously approved. No changes have been made to

this form other than those identified and marked with an underline. A summary of changes, including a

description of any deleted text is included in the filing.

Form Number and Approval Date

SERFF Filing Number

Company Name, if different

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EXACT COPY OF A PREVIOUSLY APPROVED FORM - 28 TAC §3.5(b)(3) or 28 TAC 3.1740(h)(4) Except for

the company's name, address, telephone number, or other similar identification information, the form is

an exact copy of a form that was previously approved and is still compliant with current statutes and

regulations.

Form Number and Approval Date

SERFF Filing Number

Company Name, if different

SUBSTITUTION OF A PREVIOUSLY APPROVED FORM OR EXEMPTED FORM THAT HAS NEVER BEEN

ISSUED OR USED IN TEXAS - 28 TAC §3.5(b)(4) or 28 TAC 3.1740(h)(5) A filing which substitutes a form

previously approved or exempted by the department wherein the previously approved or exempted

form has not been issued, or otherwise used in Texas, and will not be used in Texas at any time by the

company. The form number must be the same as the originally approved form.

Form Number and Approval Date

SERFF Filing Number

RESUBMISSION OF A PREVIOUSLY DISAPPROVED FORM - 28 TAC §3.5(b)(6) or 28 TAC 3.1740(h)(7) A

filing containing corrections to a form subsequent to the company receiving a disapproval letter from

the department.

Form Number and Disapproval Date

SERFF Filing Number

READABILITY - 28 TAC §3.602(b), if applicable. I certify the form(s) in this filing meet or exceed a

minimum score of 40.

8. Please include any additional information, summary of differences, statement of variability, actuarial

memorandum, etc., with the filing.

Signature

Name

Title

Date

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Appendix: Group Types (Click link for definitions and requirements)

Life Groups

TIC §1131.051 EMPLOYERS

TIC §1131.052 LABOR UNIONS

TIC §1131.053 FUNDS ESTABLISHED BY EMPLOYERS OR LABOR UNIONS

TIC §1131.054 GOVERNMENTAL ENTITIES OR ASSOCIATIONS OF PUBLIC EMPLOYEES

TIC §1131.055 SPOUSES AND CHILDREN OF EMPLOYEES OF UNITED STATES GOVERNMENT

TIC §1131.056 PRINCIPALS

TIC §1131.057 CREDITORS

TIC §1131.058 VETERANS' LAND BOARD

TIC §1131.059 ASSOCIATIONS OR TRUSTS FOR PAYMENT OF FUNERAL EXPENSES

TIC §1131.060 NONPROFIT ORGANIZATIONS OR ASSOCIATIONS

TIC §1131.064 OTHER GROUPS

TIC §1131.065 WHOLESALE, FRANCHISE, OR EMPLOYEE LIFE INSURANCE

Accident and Health Groups

TIC §1251.051 EMPLOYERS

TIC §1251.052 ASSOCIATIONS

TIC §1251.053 FUNDS ESTABLISHED BY EMPLOYERS, LABOR UNIONS, OR ASSOCIATIONS

TIC §1251.054 ELIGIBILITY FOR GROUP LIFE INSURANCE

TIC §1251.055 FUND FOR FORMER EMPLOYEES AND MEMBERS

TIC §1251.056 OTHER GROUPS

Blanket Accident and Health Groups

TIC §1251.351 COMMON CARRIER OR MOTOR VEHICLE RENTAL OR LEASING COMPANY

TIC §1251.352 EMPLOYERS

TIC §1251.353 EDUCATIONAL INSTITUTIONS

TIC §1251.354 RELIGIOUS, CHARITABLE, RECREATIONAL, EDUCATIONAL, OR CIVIC ORGANIZATION

TIC §1251.355 SPORTS TEAM OR CAMP

TIC §1251.356 GOVERNMENTAL OR VOLUNTEER EMERGENCY SERVICES ORGANIZATION

TIC §1251.357 NEWSPAPER OR OTHER PUBLISHER

TIC §1251.358 ASSOCIATION

TIC §1251.359 COVERAGE FOR OTHER RISKS