West Virginia Code of State Rules
Agency 114 - Insurance Commission
Title 114 - LEGISLATIVE RULE INSURANCE COMMISSIONER
Series 114-31 - Guaranteed Loss Ratios as Applied To Individual Sickness And Accident Insurance Policies
Appendix A - INSURANCE COMMISSIONER STATE OF WEST VIRGINIA

GUARANTEED LOSS RATIOS

INDIVIDUAL SICKNESS AND ACCIDENT INSURANCE POLICIES

INSTRUCTIONS: All questions must be answered; if no answer is applicable, enter the reason for such determination.

I. Policy form number: ________________________________

II. Anticipated lifetime and durational target loss ratios contained in the original actuarial memorandum filed with the policy form when it was originally approved:

_____________________________________________________________________________

III. First calendar year in which the loss ratio guarantee is to be effective:

_____________________________________________________________________________

IV. Source and dates of data used in determining lifetime and durational target loss ratios and credibility data:

_____________________________________________________________________________

V. Name and qualifications of the independent auditor who will perform the annual audit: _____________________________________________________________________________

VI. Attach a sample calculation and illustration of the refund methodology used to comply with the Insurance Commissioner's rule (Title 114, Series 31) entitled "Guaranteed Loss Ratios as Applied to Individual Accident and Sickness Insurance Policies."

VII. Guarantees:

(A) The actual West Virginia loss ratios for the experience period in which the new rates take effect, and for each experience period thereafter until new rates are filed, will meet or exceed the anticipated lifetime and durational target loss ratios contained in the original actuarial memorandum noted above.

(B) The actual West Virginia, or, if applicable, national, loss ratio results for the experience period at issue will be independently audited, at this company's expense, as described more fully in section 4 of this rule.

(C) If the actual loss ratio during an experience period is less than the anticipated loss ratio for that period, West Virginia policyholders shall receive proportional refunds based on premium earned, which refunds shall be calculated and paid pursuant to W. Va. Code § 33-6C-5.

(D) This company does not engage in any discriminatory practices prohibited by W. Va. Code § 33-11-4 [part of the West Virginia Unfair Trade Practices Act], or any such practice which discriminates against any individual on the basis of his or her legal occupation, race, religion or residence.

I hereby certify that the information and guarantees contained in this application are true and correct to the best of my knowledge and belief.

Company Officer's Signature: __________

(TITLE): __________

(DATE): __________