"Public Health Fee Assessment Request" - Connecticut

Public Health Fee Assessment Request is a legal document that was released by the Connecticut Insurance Department - a government authority operating within Connecticut.

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Download "Public Health Fee Assessment Request" - Connecticut

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STATE OF CONNECTICUT
INSURANCE DEPARTMENT
Public Health Fee Assessment Request
st
For Number of Insured or Enrolled Lives in CT as of May 1
, 2018
Per Conn. Gen. Stat. Sec. 19a-7p
st
Report Due Date: September 1
, 2018
I.
FILLING AS:
Domestic Insurer
Health Center
II.
REPORTING ENTITY:
Company Name:
__________________________________________________________
Street Address:
__________________________________________________________
City, State, Zip:
__________________________________________________________
Contact Person:
__________________________________________________________
Phone:
__________________________________________________________
E-Mail:
__________________________________________________________
Note: All letters and email will be sent to this address. Email should be address used for
assessment invoices.
III.
NUMBER OF INSURED OR ENROLLED LIVES IN CT:
Report Number: If none, please report as “NONE”
_______________________
st
Not later than September 1
annually, each such insurer and health care center shall report to
the Insurance Commissioner... the number of insured or enrolled lives in this state as of the
st
preceding May 1
, for which such insurer or health care center is providing health insurance
coverage of the types specified in subdivisions (1), (2), (4), (11) and (12) of section 38a-469.
Do not include lives enrolled in Medicare, any medical assistance program administered by
the Department of Social Services, workers compensation insurance or Medicare Part C plans.
(Conn. Gen. Stats. Sec. 19a-7p).
1
PUBLIC HEALTH FEE ASSESSMENT FORM
STATE OF CONNECTICUT
INSURANCE DEPARTMENT
Public Health Fee Assessment Request
st
For Number of Insured or Enrolled Lives in CT as of May 1
, 2018
Per Conn. Gen. Stat. Sec. 19a-7p
st
Report Due Date: September 1
, 2018
I.
FILLING AS:
Domestic Insurer
Health Center
II.
REPORTING ENTITY:
Company Name:
__________________________________________________________
Street Address:
__________________________________________________________
City, State, Zip:
__________________________________________________________
Contact Person:
__________________________________________________________
Phone:
__________________________________________________________
E-Mail:
__________________________________________________________
Note: All letters and email will be sent to this address. Email should be address used for
assessment invoices.
III.
NUMBER OF INSURED OR ENROLLED LIVES IN CT:
Report Number: If none, please report as “NONE”
_______________________
st
Not later than September 1
annually, each such insurer and health care center shall report to
the Insurance Commissioner... the number of insured or enrolled lives in this state as of the
st
preceding May 1
, for which such insurer or health care center is providing health insurance
coverage of the types specified in subdivisions (1), (2), (4), (11) and (12) of section 38a-469.
Do not include lives enrolled in Medicare, any medical assistance program administered by
the Department of Social Services, workers compensation insurance or Medicare Part C plans.
(Conn. Gen. Stats. Sec. 19a-7p).
1
PUBLIC HEALTH FEE ASSESSMENT FORM
IV.
CERTIFICATION:
The undersigned hereby certifies (a) that he or she duly executed this report on the date shown
below on behalf of the company named above as the Reporting Entity; (b) that he or she is an
officer or representative of such company and is authorized to make this certification; and (c)
that the facts set forth in this Report are true and correct to the best of his/her knowledge,
information and belief.
___________________________________
________________________________
BY
(signature)
(print date)
___________________________________
________________________________
(print name)
(Title)
Note: Any insurer or health care center that fails to file this report by the due date shall pay a
late filing fee for each day from the date such report was due. Also, If the Insurance
Commissioner determines that there is other than a good faith discrepancy between the actual
number of insured or enrolled lives that should have been reported and the number actually
reported, such insurer or health care center shall pay a civil penalty for each report filed for
which the Insurance Commissioner determines there is such a discrepancy. (Conn. Public Act
No.15-5).
V.
DIRECTIONS/INFORMATION:
Original ink signature not required. Emailed copy is the preferred reporting method.
Electronic Filings:
Electronic filings are preferred; sent to
cid.phfa@ct.gov
Mailing Address:
Connecticut Insurance Department
Attn: Business Office
P.O. Box 816
Hartford, CT 06142-0816
Inquiries / Questions?
Please send all inquiries to
cid.phfa@ct.gov
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PUBLIC HEALTH FEE ASSESSMENT FORM
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