2018 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

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