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THE FLORIDA DEPARTMENT OF INSURANCE, TREASURER AND FIRE MARSHAL

LIFE AND HEALTH FORMS AND RATES

- UNIVERSAL STANDARDIZED DATA LETTER INSTRUCTION SHEET-

These instructions refer to specific sections of the Universal Standardized Data Letter.

FORMS PORTION

I. Review this section for applicable filing requirements.

II. Provide the name and phone number of the individual you assign to work on this filing

Provide your FAX and E-mail address.

III. Provide company information

IX. An officer of the company must certify as to the readability of the forms.

  1. An officer of the company or a designated compliance person must certify that all the information provided is correct.

  1. Title is the name of the product, for example "Trendsetter 20." Type of form is the type of insurance policy, such as "Term Life Insurance Policy." Replaced Form number is the number of the form, which will be discontinued for future sales that you are replacing, if applicable. This does not mean individual insureds are having their coverage cancelled and replaced. New Form number is the form number you have at the time of filing.

Additional Forms Information:

  1. A letter of transmittal explaining the type and nature of the filing.

  1. Do not include filings for more than one company with each submission.

  2. Complete the appropriate checklist for each filing.

  3. A certification that the representative making the filing, if someone other than a company employee, has been authorized to do so by an officer of the company.

  4. Advertisement should be submitted as a separate filing and not as part of a form filing.

  5. When responding to Department correspondence regarding a filing, please correspond directly with the analyst, referencing our file number.

  6. The complete filing should be sent to:

Bureau of L & H Forms & Rates
Florida Department of Insurance

PO Box 8040

Tallahassee, Florida 32301-8040

Telephone Number: (904) 922-3152

RATES PORTION

IV. General Information:

This form needs to be filled out for all filings, even Annual Rate Filing Certifications.

IV. C. Group Policy Characteristics:

Employee Group: (Life Section 627.552 / Health Section 627.653 F.S.)

1. The group policy may include provisions for retired employees and,

2. May include the spouse or dependent children with or without the employee being insured.

Labor Union Groups: (Life Section 627.554 / Health Section 627.654 F.S.)

1. The group policy must cover at least 25 persons.

2. Excluding officers of the association, as least 15 persons must be covered.

3. The group must be organized for 1 year for purposes other than that of obtaining insurance.

4. The dependents may be insured without the member of the group.

Debtor Group: (Life Section 627.553 / Health Section 627.655 F.S.)

1. The group policy may be issued if there are at least 100 new entrants each year, or

2. The expected number of entrants must be at least 100 if the policy is new.

3. The insurer may reserve the right to require evidence of individual insurability if less than 75 percent of the new entrants

become insured.

Association Groups: : (Life Section 627.5567 / Health Section 627.654 F.S.)

1. The member must be engaged in a particular profession in Florida.

2. The group must have been associated for at least 2 years and,

3. Must meet at least once a year.

Additional Group: (Life Section 627.5565 / Health Section 627.656 F.S.)

1. If the company is authorized to have a Group Life policy in Florida, it may insure any group of individuals for Health

Insurance that could be insured under such Group Policy.

2. However, there is an exception for Credit Union groups. One may also have Credit Union health policy groups, but the

benefits of the policy should not exceed $10,000.

Blanket Health Insurance: (Section 627.659, F.S.)

The following are eligible groups:

1. Employee groups where uniform criterion are used for providing insurance to individuals who face similar circumstances, such as common job hazards.

2. Academic institutions where the group insured are teachers and students. Spouse or dependent children of the insured student may be covered.

3. Members of a Volunteer Group.

4. Organizations of a religious, educational, instructive, recreational, or similar nature. Examples are Boy Scouts of America, the Future Farmers of America, summer camps, and so on.

5. Newspapers covering independent contractor newspaper boys.

6. Health Care provider covering patients. This coverage may not be a condition of receiving care.

7. Licensed Health Maintenance Organizations (HMO).

Franchise Health Insurance: (Section 627.663, F.S.)

1. Two or more employees of any corporation, professional association, copartnership, or individual employer or of any governmental corporation, agency, or department; or

2. Ten or more individuals who are members of any trade association or labor union or any other association having had an active existence for at least 2 years if such association or union has a constitution or bylaws and is formed in good faith for purposes other than that of obtaining insurance.

IV. D. Optionally Renewable:

Renewal can be declined at the option of the insurance company.

Conditionally Renewable:

Renewal can be declined by class, by geographic area or for stated reasons other than the deterioration of health.

Guaranteed Renewable:

Renewal cannot be declined by the insurance company for any reason, but the insurance company can revise rates on a class basis. (see also Sections 627.6425 & 627.6571, F.S.)

Non-Cancelable:

Renewal cannot be declined nor can the rates be revised by the insurance company.

Non-Renewable:

There is a contractual provision which prevents a policy duration of more than one year.

V. RATE FILING HISTORY - To be completed for all policies whose rates are subject to regulatory authority such as all health insurance.

This section is for Florida experience only on the total of forms combined for this filing. Please provide the information for the current filing and the two most recent rate revision filings if applicable:

(1) Rate change requested - the percentage increase in the average annual premium. The average annual premium should be calculated on the basis of the inforce distribution.

(2) Total Annualized Premium Volume - Total premium volume, on an annual premium basis, for the inforce policies at the time of the related filing.

(3) Number of Certificates or Policies - For group provide the number of individual certificates or subscribers in force, and the number of policies for individual.

(4) Average Rate Change - The amount of rate revision approved, expressed as the percentage increase in the average annual premium.

(5) Maximum Rate Change - The largest increase affecting any specific policyholder.

(6) Date Change Approved - The Department's date of approval of the rate revision filing.

(7) Florida Filing Number – the Florida filing number, i.e. FLR 98-1234, which identifies the filing

VI. RATE REQUEST BY FORM - To be completed for all policies whose rates are subject to regulatory authority such as all health insurance. This section should be completed only if two or more forms are included in the filing.

This section is for Florida experience only.

(1) Form Number - The form number of the form being filed.

(2) Rate change requested - the percentage increase in the average annual premium. The average annual premium should be calculated on the basis of the inforce distribution.

(3) Total Annualized Premium Volume - Total premium volume, on an annual premium basis, for the inforce policies at the time of the related filing.

(4) Number of Certificates or Policies - For group provide the number of certificates in force, and the number of policies for individual.

VII. ADDITIONAL DATA - To be completed for all policies whose rates are subject to regulatory authority such as all health insurance. (Do Not Reference Attachments)

A. Number of Certificates or Policies Affected - For group provide the number of individual certificates or subscribers in force, and the number of policies for individual.

B. Average Number of Certificates Per Policy - If group. (A  B should yield the average number of groups)

C. Annualized Premium - Premium volume, on an annual premium basis, for the current inforce policies.

D. Average Annual Premium - The average annual premium based on the inforce age/sex/area, etc. distribution of inforce policies. The average annual premium for a new policy form should be included here.

E. Anticipated Loss Ratio - The present values of future claims, divided by the present value of future earned premiums on

the proposed rate basis over the block of business. This should also be included for new form filings. Current is before

any rate change.

F. Lifetime Loss Ratio - The present value of incurred claims, past and expected future, divided by the present value of

earned premiums, past, and expected future on both the current and proposed rate basis. Current is before any rate change.

G. The originally filed loss ratio standard for the form. If the standard has been increased in prior rate filings due and

certifications of a higher standard, this should reflect this higher standard.

H. Total Past Incurred Loss Ratio Without Reserve Increases - The accumulated value of past-incurred claims divided by the

accumulated value of the past earned premiums.

I. Current Year Loss Ratio for Policies 3 Years and Older without Policy Reserves - The same definition as (I).

VIII. This certification must be signed by an actuary who is a member of the Society of Actuaries or the American Academy of Actuaries, and is knowledgeable and experienced in the insurance topic applicable to the form being certified, or if the company does not employ one, company personnel or consultant with a minimum of 5 years experience in health insurance rate making, or the chief executive officer of the insurer. This is in connection with the annual rate filing requirements as defined in Florida Statute 627.410(7).

3

DI4-1507A (Instructions)

1/02



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