"Consent to Rate Form" - New Hampshire

Consent to Rate Form is a legal document that was released by the New Hampshire Insurance Department - a government authority operating within New Hampshire.

Form Details:

  • Released on February 28, 2006;
  • The latest edition currently provided by the New Hampshire Insurance Department;
  • Ready to use and print;
  • Easy to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of the form by clicking the link below or browse more documents and templates provided by the New Hampshire Insurance Department.

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Download "Consent to Rate Form" - New Hampshire

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STATE OF NEW HAMPSHIRE
INSURANCE DEPARTMENT
CONSENT TO RATE FORM
(Must be accompanied by declarations page showing name, location and address.)
NAMED INSURED AND MAILING
INSURANCE COMPANY AND
ADDRESS
MAILING ADDRESS
Policy Number_____________________
Policy Term_______________________
REASON(S) FOR EXCEPTION TO FILED RATE(S) - RSA 412:16X:
Describe exposure(s) or any substandard, unusual or hazardous conditions which necessitates the use of a
rate or premium not filed with the Department. Include any underwriting information in support of the
proposed rating. Reasons that merely refer to a policyholder’s inability to obtain coverage at standard
rates, or comments that essentially equate to “class of risk” are not acceptable.
_____ _Unusual hazard involved
_______Unfavorable loss experience
_____ _Other
Explanation of above reason(s)
Premium at filed rate(s)______________
Premium at Consent Rate(s)_______________
I HEREBY CERTIFY AND I UNDERSTAND THAT THE PREMIUM CHARGE FOR
THIS POLICY (ENDORSEMENT) IS NOT STANDARD.
__________________________________
____________________
Policyholder Signature
Date
_______________________________
Title
The signature by the policyholder or an authorized representative of the policyholder (NOT the insurance
agent) must be made after this form has been completed.
28-Feb-2006
STATE OF NEW HAMPSHIRE
INSURANCE DEPARTMENT
CONSENT TO RATE FORM
(Must be accompanied by declarations page showing name, location and address.)
NAMED INSURED AND MAILING
INSURANCE COMPANY AND
ADDRESS
MAILING ADDRESS
Policy Number_____________________
Policy Term_______________________
REASON(S) FOR EXCEPTION TO FILED RATE(S) - RSA 412:16X:
Describe exposure(s) or any substandard, unusual or hazardous conditions which necessitates the use of a
rate or premium not filed with the Department. Include any underwriting information in support of the
proposed rating. Reasons that merely refer to a policyholder’s inability to obtain coverage at standard
rates, or comments that essentially equate to “class of risk” are not acceptable.
_____ _Unusual hazard involved
_______Unfavorable loss experience
_____ _Other
Explanation of above reason(s)
Premium at filed rate(s)______________
Premium at Consent Rate(s)_______________
I HEREBY CERTIFY AND I UNDERSTAND THAT THE PREMIUM CHARGE FOR
THIS POLICY (ENDORSEMENT) IS NOT STANDARD.
__________________________________
____________________
Policyholder Signature
Date
_______________________________
Title
The signature by the policyholder or an authorized representative of the policyholder (NOT the insurance
agent) must be made after this form has been completed.
28-Feb-2006