New Jersey Insurer Rate Filing-Adoption Of Advisory Organization-Prospective Loss Cost Summary Of Supporting Information Form

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11:13-APPENDIX A
APPENDIX A
Date of Filling Out Form:_______
Space Reserved for Insurance
N E W J E R S E Y I N S U R E R R A T E F I L I N G
D e p a r t m e n t U s e _ _ _ _ _ _ _ _
ADOPTION OF ADVISORY ORGANIZATION
P R O S P E C T I V E L O S S C O S T
S U M M A R Y O F S U P P O R T I N G I N F O R M A T I O N F O R M
1.
INSURER NAME:_________________________________________________
ADDRESS:______________________________________________________
_______________________________________________________________
_______________________________________________________________
PERSON RESPONSIBLE FOR FILING:_______________________________
TITLE:_______________________________ TELEPHONE #:_____________
2.
INSURER GROUP NAIC #:_________________________________________
2A.
INSURER COMPANY NAIC #:_______________________________________
3.
LINE OF INSURANCE:_____________________________________________
4.
ADVISORY ORGANIZATION:_______________________________________
5.
ADVISORY ORGANIZATION REFERENCE FILING #:____________________
6.
The above insurer hereby declares that it is a member, subscriber or service purchaser of the named
advisory organization for this line of insurance. The insurer hereby files to be deemed to have
independently submitted as its own filing the prospective loss costs in the captioned Reference Filing.
T h e ins u r e r ’s r a t e s w i l l b e t h e c o mb in a ti o n o f t h e p r o s p e c tiv e l o s s c o s ts a n d
t h e l o s s c o s t m u l t i p l ie r s .
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.)
“ The Fi l ed Loss C os t L e ve l C ha ng e Fac to r fo r th e i ni t ia l f il i ng is t he R at i o o f
R e v is e d Lo s s C os ts to C u r r en t R a tes d i v ide d by th e D e v i atio n w h ich th e i ns ur e r
a pp li ed to t he C u r r en t R a tes ( e xp r es s ed as a d ec i ma l) ; a nd for s ubs eque n t fi l i n g s ,
t h e R a t io o f R e vis ed L os s C os t L e ve l to C u r r ent Loss C o s t Le ve l .”
5-15-95
13-11

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