Fillable Reference Filing Adoption Form printable pdf download

Date:____________________________

MISSISSIPPI

Space reserved for Insurance

INSURER RATE FILING

Department Use

ADOPTION OF RATE SERVICE ORGANIZATION

PROSPECTIVE LOSS COSTS

REFERENCE FILING ADOPTION FORM

1. INSURER NAME:________________________________________________________________

ADDRESS:______________________________________________________________________

______________________________________________________________________

ENTER CITY HERE_________________________State________Zip_________________

PERSON RESPONSIBLE FOR FILING__________________________________________________

TITLE

2. INSURER NAIC#__________________________________________________________________

3. LINE OF INSUR NCE ______

4. RATE SERVICE ORGANIZATION______________________________________________________

5. RATE SERVICE ORGANIZATION REFERENCE FILING #_____________________________________

6. The above insurer hereby declares that it is a member, subscriber or service purchaser of the named rate

service organization for this line of insurance. The insurer hereby filed to be deemed to have

independently submitted as its own filing the prospective loss costs in the captioned Reference Filing.

The insurer’s rates will be the combination of the prospective loss costs and the loss cost multipliers and,

if utilized, the expense constants specified in the attachments.

7. PROPOSED RATE LEVEL CHANGE ______________% EFFECTIVE DATE_____________________

8. PRIOR RATE LEVEL CHANGE__________________% EFFECTIVE DATE_____________________

9. ATTACH “SUMMARY OF SUPPORTING INFORMATION FORM”

(Use a separate Summary for each insurer‐selected loss cost multiplier)

10. CHECK ONE OF THE FOLLOWING:

The insurer hereby files to have its loss cost multipliers and, if utilized, expense accounts be applicable to

future revisions of the rate service organization’s prospective loss costs for this line of insurance. The

insurer’s rates will be the combination of the rate service organization’s prospective loss costs and the

insurer’s loss cost multipliers and, if utilized, expense constants specified in the attachments. The rates will

apply to policies written on or after the effective date of the rate service organization’s prospective loss costs.

This authorization is effective until disapproved by the Commissioner, or amended or withdrawn by

the

insurer.

The insurer hereby files to have its loss cost multipliers and, if utilized, expense constants

be applicable only to the above Rate Service Organization Reference Filing.

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Reference Filing Adoption Form