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

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

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 NumberFax 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.)
IndividualGroupChapter 1131
Section
Chapter 1251
Section
2. Select the product being submitted
A.
Accident and HealthLife, Accident and HealthEPO - Exclusive Provider Plan
Life
Long Term CareLife Settlement
Annuity
Medicare SupplementNonprofit Prepaid Legal
Credit
Medicare SELECT
Business Change (Name Change, Merger)
B. Select as applicable
Audit RevisionsConsumer 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
Texas Department of Insurance | www.tdi.texas.gov
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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
Form number and brief description
Form number and brief description
Form number and brief description
Form number and brief description
B.
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
Form Number and SERFF Filing Number
Form Number and SERFF Filing Number
Texas Department of Insurance | www.tdi.texas.gov
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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:
InitialSubsequentAnnualInformational
Increase
Percentage
Decrease
Percentage
Form Number and SERFF Filing Number
Form Number and SERFF Filing Number
Form Number and SERFF Filing Number
Form Number and SERFF Filing Number
ATTENTION: Fees remitted for rejected filings will not be refunded or applied to future submissions.
Texas Department of Insurance | www.tdi.texas.gov
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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
Texas Department of Insurance | www.tdi.texas.gov
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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
Texas Department of Insurance | www.tdi.texas.gov
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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 §1251.053FUNDS 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
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