Form HIPMC-R36 "Rate Filing Information Form (Limited Benefits)" - Kentucky

What Is Form HIPMC-R36?

This is a legal form that was released by the Kentucky Department of Insurance - a government authority operating within Kentucky. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on July 1, 2020;
  • The latest edition provided by the Kentucky Department of Insurance;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form HIPMC-R36 by clicking the link below or browse more documents and templates provided by the Kentucky Department of Insurance.

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Download Form HIPMC-R36 "Rate Filing Information Form (Limited Benefits)" - Kentucky

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Kentucky Department of Insurance
Division of Health and Life Insurance
Health Care Financing Branch
*RATE FILING INFORMATION FORM (Limited Benefits)
* (
This form is not required with Health Benefit Plan Rate Filings in KRS 304.17A)
__________________________________________________________
__________________________________
Company
NAIC Company No.
__________________________________________________________
__________________________________
Contact Person
E-Mail Address
________________________________
____________________
__________________________________
Phone No. (800 # if available)
EXT.
Fax Number
_________________________________________________________
___________________________________
Form No(s).
No of Forms
************************************************************************************************************
CHECK ALL APPLICABLE:
* This does not apply to Health Benefit Rate Filings
TYPE OF POLICY:
Accident
Hospital/Medical/Surgical
Long Term Care
Cancer
Short Term Limited Duration
Short Term Nursing Home
Dental
Specified Disease
Medicare Supplement Pre-Standardized
Disability
Student
Medicare Supplement Standardized
Home Health
Vision
Medicare Supplement Modernized
Hospital Indemnity
LTCPI (LTC Partnership Insurance)
Other __________________________
REQUIRED ANNUAL MEDICARE SUPPLEMENT FILING:
MARKET TYPE:
Individual
Group
KY Retirement/Group Seniors
AVAILABILITY:
PREMIUM STRUCTURE:
Closed Block
Open Block
Attained Age
Issue Age
Community
Other_________________________________
RENEWAL CATEGORIES:
OR-Optionally renewable
CR- Conditionally renewable
GR- Guaranteed renewable
NC- Noncancelable
FILING INFORMATION:
Range in Rate Structure (area, age slope, etc.) Yes______ No ______
Previous Rate Filing DOI #_______________
Rate % Increase Requested: ________________
Range of Rate Increase: ___________________
Estimated Average Annual Premium before Increase: _________________
Estimated Average Annual Premium after Increase: _________________
No. of Kentucky Policies: _________________________
No. of National Policies: _______________________
Requested Filing Effective Date: ___________________
Original Filing Date:
_______________________
Previous Increase Effective Date: __________________
Amount of Last Approved Increase: _____________
HIPMC-R36 (07/2020)
Page 1 of 1
Kentucky Department of Insurance
Division of Health and Life Insurance
Health Care Financing Branch
*RATE FILING INFORMATION FORM (Limited Benefits)
* (
This form is not required with Health Benefit Plan Rate Filings in KRS 304.17A)
__________________________________________________________
__________________________________
Company
NAIC Company No.
__________________________________________________________
__________________________________
Contact Person
E-Mail Address
________________________________
____________________
__________________________________
Phone No. (800 # if available)
EXT.
Fax Number
_________________________________________________________
___________________________________
Form No(s).
No of Forms
************************************************************************************************************
CHECK ALL APPLICABLE:
* This does not apply to Health Benefit Rate Filings
TYPE OF POLICY:
Accident
Hospital/Medical/Surgical
Long Term Care
Cancer
Short Term Limited Duration
Short Term Nursing Home
Dental
Specified Disease
Medicare Supplement Pre-Standardized
Disability
Student
Medicare Supplement Standardized
Home Health
Vision
Medicare Supplement Modernized
Hospital Indemnity
LTCPI (LTC Partnership Insurance)
Other __________________________
REQUIRED ANNUAL MEDICARE SUPPLEMENT FILING:
MARKET TYPE:
Individual
Group
KY Retirement/Group Seniors
AVAILABILITY:
PREMIUM STRUCTURE:
Closed Block
Open Block
Attained Age
Issue Age
Community
Other_________________________________
RENEWAL CATEGORIES:
OR-Optionally renewable
CR- Conditionally renewable
GR- Guaranteed renewable
NC- Noncancelable
FILING INFORMATION:
Range in Rate Structure (area, age slope, etc.) Yes______ No ______
Previous Rate Filing DOI #_______________
Rate % Increase Requested: ________________
Range of Rate Increase: ___________________
Estimated Average Annual Premium before Increase: _________________
Estimated Average Annual Premium after Increase: _________________
No. of Kentucky Policies: _________________________
No. of National Policies: _______________________
Requested Filing Effective Date: ___________________
Original Filing Date:
_______________________
Previous Increase Effective Date: __________________
Amount of Last Approved Increase: _____________
HIPMC-R36 (07/2020)
Page 1 of 1