North Carolina Administrative Code
Title 11 - INSURANCE
Chapter 10 - PROPERTY AND CASUALTY DIVISION
Section .1200 - FORMS FILINGS
Section 10 .1207 - FORM(S) QUESTIONNAIRE

(1) name of the filer;

(2) Federal Employer's 11 Digit Number;

(3) filer's file number;

(4) program title;

(5) line(s) of insurance;

(6) how many new forms and/or revised forms are being filed;

(7) list all old form(s) being withdrawn and department file number(s);

(8) explain the purpose(s) of this filing;

(9) list the states where this filing has been made;

(10) action taken by domiciliary state if form has been filed in that state;

(11) list the states that have approved this filing;

(12) list the states that disapproved this filing and reason(s) for disapproval;

(13) copies of all required modifications referred to in Paragraph (12) of this Rule;

(14) if the filing is similar or identical to a filing made with the N.C. Department of Insurance by a licensed bureau or licensed rating organization, complete the following:

(15) if the filing is similar or identical to a filing made with the N.C. Department of Insurance by a licensed insurance company in North Carolina, give the N.C. Insurance Department file number and approval date. Also, describe the difference(s) if any, between your form(s) and those of the previously approved program;

(16) computer printed declarations pages should be completed in "John Doe" fashion;

(17) proposed effective date and rule of implementation;

(18) a certification of the accuracy of the filing by an officer of the company or head of the filings department.