ࡱ> knhij  bjbjBrBr Oh  -8luNc" %."G.G.G./;2T3sssssssgw zs;4//;4;4sG.G.pt555;4pG.G.s5;4s550h4mG.wd4dj<st0ujTz5.zxmzm;4;45;4;4;4;4;4ss5;4;4;4u;4;4;4;4z;4;4;4;4;4;4;4;4;4 : What is the purpose of this filing? (Check one)  FORMCHECKBOX  Forms Only  FORMCHECKBOX  Forms & Rates  FORMCHECKBOX  Rates Only  FORMCHECKBOX  Annual Rate Certification (no rate or benefit changes) Company Information: FEIN FORMTEXT      NAIC Company Code  FORMTEXT      Company Name FORMTEXT       SECTION I. INSTRUCTIONS AND INFORMATION This online form must accompany all Life & Health Form or Rate filings submitted to the Office. If you have questions regarding the information requested, please consult our website at HYPERLINK "http://www.floir.com/" \t "_blank"www.floir.com or contact us at (850) 413-3152. SECTION II. CONTACT INFORMATION Preferred Email Address: (for all correspondence)  FORMCHECKBOX  I-Portal Account Email  FORMCHECKBOX  Filing Originator Email  FORMCHECKBOX  Company Contact Email  FORMCHECKBOX  Other Additional Email Addresses: Filing Originator Information FORMCHECKBOX  Dr.  FORMCHECKBOX  Mr.  FORMCHECKBOX  Mrs.  FORMCHECKBOX  Ms.  FORMCHECKBOX  MissContact Name:Contact Title:Professional Designation:Contact Email:Street Address:Suite/Room #:P.O. Box Mailing Address:Department:City:State:Zip Code:-Country:Non US Postal Code:Phone Number:ExtFax Number:Toll Free Number:ExtNon US Phone Number:Company Contact Information FORMCHECKBOX  Dr.  FORMCHECKBOX  Mr.  FORMCHECKBOX  Mrs.  FORMCHECKBOX  Ms.  FORMCHECKBOX  MissContact Name:Contact Title:Professional Designation:Contact Email:Street Address:Suite/Room #:P.O. Box Mailing Address:Department:City:State:Zip Code:-Country:Non US Postal Code:Phone Number:ExtFax Number:Toll Free Number:ExtNon US Phone Number: SECTION III. GENERAL INFORMATION A. Do you currently have in force business on this plan of insurance in Florida?  FORMCHECKBOX Yes  FORMCHECKBOX No B. Are you currently selling this plan in other states?  FORMCHECKBOX Yes  FORMCHECKBOX No C. What market restrictions (such as available to military persons only), do you have on this form?  FORMTEXT       D. Is this filing a resubmission of a previously disapproved, withdrawn or incomplete filing?  FORMCHECKBOX Yes  FORMCHECKBOX No If yes, provide Florida file log number:  FORMTEXT       E. Type of company:  FORMCHECKBOX Profit  FORMCHECKBOX Non-profit SECTION IV. LIFE & HEALTH INSURANCE A. Your policy or coverage is (check one)  FORMCHECKBOX  Health  FORMCHECKBOX  Life  FORMCHECKBOX  Variable Life  FORMCHECKBOX  Annuity  FORMCHECKBOX  Variable Annuity B. Your policy or coverage is (Check one)  FORMCHECKBOX  Fraternal  FORMCHECKBOX  Individual  FORMCHECKBOX  Group C. Group Policy Characteristics 1)  FORMCHECKBOX  In-state  FORMCHECKBOX  Out-of-state 2)  FORMCHECKBOX  Large Group Only  FORMCHECKBOX  Small Group Only (Major Medical - see section 627.6699, F.S.)  FORMCHECKBOX  Small Group Only (Other than Major Medical)  FORMCHECKBOX  Small and Large Groups (Other than Major Medical) 3)  FORMCHECKBOX  Employee Group  FORMCHECKBOX  Labor Union Group  FORMCHECKBOX  Debtor Group  FORMCHECKBOX  Association Group  FORMCHECKBOX  Additional Group  FORMCHECKBOX  Other (specify)  FORMTEXT       4)  FORMCHECKBOX  Blanket Health Policy  FORMCHECKBOX  Franchise Health Policy  FORMCHECKBOX  A group to cover persons associated in any other common group, which common group is formed primarily for purposes other than providing insurance.  FORMCHECKBOX  A group which is established primarily for the purpose of providing group insurance.  FORMCHECKBOX  A group of insurance agents of an insurer, which insurer is the policyholder.  FORMCHECKBOX  Other (specify)  FORMTEXT       D. Individual Policy Characteristics  FORMCHECKBOX  Optionally Renewable  FORMCHECKBOX  Guaranteed Renewable  FORMCHECKBOX  Non-Renewable  FORMCHECKBOX  Conditionally Renewable  FORMCHECKBOX  Non-Cancelable  FORMCHECKBOX  Other (specify)  FORMTEXT       E. Is your Policy or Coverage primarily for individuals over 65?  FORMCHECKBOX  Yes  FORMCHECKBOX  No F. Check the types of benefit(s) your policy or coverage provides:  FORMCHECKBOX Disability Income FORMCHECKBOX Major Medical FORMCHECKBOX Long Term Care FORMCHECKBOX Prepaid Limited Health Service Organization FORMCHECKBOX Medicare Supplement FORMCHECKBOX Small Employer Group Coverage (see Section 627.6699, F.S.) FORMCHECKBOX Health Maintenance Organization FORMCHECKBOX Other (specify)  FORMTEXT       SECTION V. RATE FILING HISTORY  INCLUDING ANNUAL RATE CERTIFICATIONS (This section is for Florida experience only; not applicable for new form filings) (1)(2)(3)(4)(5)(6)(7)(8)(9)(10)Total Annualized Premium Volume# of Group Certificates or Individual PoliciesAverage Rate Change Requested (0.0% for ARC Filings)Minimum Rate Change Requested (0.0% for ARC Filings)Maximum Rate Change Requested (0.0% for ARC Filings)Average Benefit Change Requested (0.0% for ARC Filings)Effective Date of Change (N/A for ARC Filings)Current Filing$ FORMTEXT       FORMTEXT      Average Rate Change RequestedTotal Annualized Premium Volume# of Group Certificates or Individual PoliciesAverage Rate Change ApprovedMinimum Rate Change ApprovedMaximum Rate Change ApprovedAverage Benefit Change ApprovedDate Change Approved or AcknowledgedFlorida Filing NumberEffective Date of Change1st Prior Filing FORMTEXT      %$ FORMTEXT       FORMTEXT       FORMTEXT      % FORMTEXT      % FORMTEXT      % FORMTEXT      % FORMTEXT       FORMTEXT       FORMTEXT      2nd Prior Filing FORMTEXT      %$ FORMTEXT       FORMTEXT       FORMTEXT      % FORMTEXT      % FORMTEXT      % FORMTEXT      % FORMTEXT       FORMTEXT       FORMTEXT      NOTE: Dates for columns (8) and (10) must be in the format mm/dd/yyyy. SECTION VI. RATE REQUEST BY FORM  INCLUDING NEW FORM SUBMISSIONS (To be completed for all rate filings, including ARC filings - Florida experience only.) (1) Form Number(2) Base Form or Rider(3) Marketing Product Name (Street Name)(4) Average Rate Change Requested (0.0% for ARC Filings)(5) Minimum Rate Change Requested (0.0% for ARC Filings)(6) Maximum Rate Change Requested (0.0% for ARC Filings)(7) Average Benefit Change Requested (0.0% for ARC Filings)(8) Total Annualized Premium Volume(9) Total Incurred Claims(10) # of Group Certificates or Individual Policies(11) # of Covered Dependents/Additional Lives (12) # of Covered Lives (10+11)(13) Inception Date or New Form(14) Discontinued Date (If Applicable)(15) Number of Member Months (Major Medical Only)(16) Major Medical Coverage Type (Select All That Apply)HMO, PPO, Indemnity, POS, FFS, EPO, HSA, HDHP MAJOR MEDICAL FORMS ONLY Please enter one claim per row for each unique incurred claim over $500,000 for last five (5) years by year: (1) Amount(2) Incurral Year SECTION VII. ADDITIONAL DATA FOR ALL RATE FILINGS (Please provide current data for the form(s) included in the filing and listed in section VI.) Florida OnlyNationwide FORMCHECKBOX  Same as FloridaA. Number of Group Certificates or Individual Policies FORMTEXT       FORMTEXT      B. If Group, Average Number of Certificates Per Policy/ Participating Unit (e.g. Employer Unit)  FORMTEXT       FORMTEXT      C. 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0(($*$Ifxkd$$Ifl4\X D!+$  8,44 laf4ytM'8T7|77777777777777777777778$&(*ϠϠtϠr\ϠU hjhM'8+jhjh9CJOJQJU^JU+jhjh9CJOJQJU^J+j$hjh9CJOJQJU^J0jhjhM'8CJOJQJU^JmHnHu+jhjh9CJOJQJU^J%jhjh9CJOJQJU^JhjhM'8CJOJQJ^Jhjh6feCJOJQJ^J  FORMTEXT      D. Total Incurred Claims (Prior / Projected)$ FORMTEXT      $ FORMTEXT      $ FORMTEXT      $ FORMTEXT      E. Average Annual Premium (Current / Proposed or new form)$ FORMTEXT      $ FORMTEXT      $ FORMTEXT      $ FORMTEXT      F. Anticipated Loss Ratio (Current / Proposed Premium) FORMTEXT      % FORMTEXT      % FORMTEXT      % FORMTEXT      %G. Lifetime Loss Ratio (Current / Proposed Premium) FORMTEXT      % FORMTEXT      % FORMTEXT      % FORMTEXT      %H. Target Loss Ratio for Individual or Group Forms (Not the Minimum; Expected Loss Ratio for Annually Rated Groups; Weighted average by form and/or group size where applicable) FORMTEXT      % FORMTEXT      %I. Total Past Incurred Loss Ratio Without Active Life Reserve Increases FORMTEXT      % FORMTEXT      %J. Latest Calendar Year Loss Ratio for Policies 3 Years & Older (For Med. Supp.) Without Policy Reserves: FORMTEXT      % FORMTEXT      %K. Anticipated Actual-to-Expected Loss Ratio (Current / Proposed)%%%%L. Lifetime Actual-to-Expected Loss Ratio (Current / Proposed)%%%%M. Total Past Actual-to-Expected Loss Ratio %%N. Valuation Date of Data (applies to all data in this section) FORMTEXT       FORMTEXT       SECTION VIII. Rate Filing Certification I certify that I am authorized to make this Rate Filing on behalf of the company, further that the information contained in related transmittals and the filing is true, complete, correct, and in compliance with all applicable state laws. (Check one)  FORMCHECKBOX  I am an actuary  FORMCHECKBOX  I am not an actuary Name:  FORMTEXT      Title:  FORMTEXT       SECTION IX. Readability Certification If you are not required to certify READABILITY compliance per Section 627.4145, F.S., please complete Section IX by checking the box, typing your name and substituting "READABILITY NOT APPLICABLE" in the title field. I certify that the filing of this policy meets the requirements of Section 627.4145 (1), Florida Statutes, in the following manner (check one)  FORMCHECKBOX  the policy meets the minimum reading ease test score on the test used or;  FORMCHECKBOX  the score is lower than the minimum required but should be approved in accordance with Subsection 627.4145 (2), Florida Statues. I acknowledge that the Office may require the submission of further information to verify this certification. Name:  FORMTEXT      Title:  FORMTEXT       SECTION X. Checklist Certification I have reviewed or supervised the review of the policy form(s) that this filing describes. I hereby certify that the statements made in this filing are in compliance with applicable Florida Statutes and Rules. I further certify it will be revised and/or discontinued if the Office determines that the form(s) does not comply with Florida law. Name:  FORMTEXT      Title:  FORMTEXT       SECTION XI. Forms To Be Reviewed Please provide the following information for the form(s) submitted with this filing. Form TitleForm NumberOriginal Filing NumberOriginal Form Number FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT          Department of Financial Services Office of Insurance Regulation  Bureau of Life & Health Forms and Rates UNIVERSAL STANDARDIZED DATA LETTER PAGE  PAGE 1 OIR-B2-1507 Rev. 8/12 (*`M:::: 0(($*$Ifgd  0(($*$Ifgd_kdb$$Ifl4ֈX D!&+$VJh 8,44 laf4ytM'8*,>\  ",.026ϠϠtϠ^ϠW hjh{+j˃hjh9CJOJQJU^J+jahjh9CJOJQJU^J+jhjh9CJOJQJU^J0jhjh{CJOJQJU^JmHnHu+jhjh9CJOJQJU^J%jhjh9CJOJQJU^Jhjh{CJOJQJ^JhjhHCJOJQJ^J"02M:* 0(($*$If 0(($*$IfgdDkd5$$Ifl4ֈX D!&+$VJh 8,44 laf4yt  0(($*$Ifgd 6fhxz|&(,.B{e+j4hjh9CJOJQJU^J+jʅhjh9CJOJQJU^J0jhjhNCJOJQJU^JmHnHu+j`hjh9CJOJQJU^J%jhjh9CJOJQJU^Jhjh4 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