2018 Public Health Fee Assessment Request - Connecticut

This printable "Public Health Fee Assessment Request" is a document issued by the Connecticut Insurance Department specifically for Connecticut residents.

Download a PDF of the latest edition of the form down below or find it through the department's forms library.

ADVERTISEMENT
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
2
PUBLIC HEALTH FEE ASSESSMENT FORM

Download 2018 Public Health Fee Assessment Request - Connecticut

437 times
Rate
4.8(4.8 / 5) 31 votes
ADVERTISEMENT
Page of 2