ANNUAL FILING REQUIREMENT
MUST BE COMPLETED AND RECEIVED BY March 1, 2009

 

 
Company Name:  
Company Address:  

 

  

 
IDAHO
Individual and/or Small Employer Health
REINSURANCE PROGRAM
Under Idaho Code § 41-4711(12)(c) and Idaho Code 41-5508(3)(b), assessments for the reinsurance program are determined by each carrier's share of the assessable market. In Idaho the assessable market includes all disability premium where Idaho premium is reportable:
  1. Health benefit plans;
  2. Specific disease coverages;
  3. Hospital confinement indemnity coverages and
  4. Reinsurance by way of excess loss and stop-loss.
This information is necessary to determine each carrier's proper level of assessment in support of the program.
NOTE: Assessments cannot be offset against premium or other taxes due.
This form is not an assessment. The information will be used to determine your annual assessment, which will then be billed under separate cover. You are required by Idaho Code§ 41-247 to promptly and accurately respond to this request for information.
Reporting Period: Calendar Year 2008
ANNUAL STATEMENT RECONCILIATION WORKSHEET
Total direct Idaho Premiums Earned or Subscriber Charges:
Life and Accident & Health
Life Insurance (State Page) 25, line 26, col. 2
*Including re-insurance by way of excess loss and stop-loss 		 
Property & Casualty
Exhibit of Premiums and Losses (State Page) 20, sum of lines 13, 15.1 thru 15.8, 16, col. 2
*Including re-insurance by way of excess loss and stop-loss 		 
Health
Exhibit of Premiums, Enrollment and Utilization (State Page) 30, line 15, col. 1
*Including re-insurance by way of excess loss and stop-loss 		 
Fraternal
Life Insurance (State Page) 24, line 26, col. 2
*Including re-insurance by way of excess loss and stop-loss 		 
Deduct the following, if included in the above:
Federal Employee Health Benefit Plans  
Nonrenewable short-term medical  
Automobile medical payment  
Student health benefits only - issued as a supplement to liability insurance  
Workers compensation or similar coverage  
Supplemental liability insurance  
Credit insurance  
Accident only  
Dental and vision  
Income continuation  
Loss of time / Disability Income  
Medicare Advantage  
Medicare supplemental insurance  
Medicare Part D  
Long-term care insurance (As defined under chapter 46, title 41 Idaho Code)  
Excess Loss (Stop Loss)Reinsurance - to insured or self-insured groups (employers)  
Total Deductions ($  ) 
TOTAL 2009 Assessment Base $  
TOTAL NUMBER OF RESIDENTS AS OF DECEMBER 31, 2008 : Based on Idaho Code Sections 41-4711(16) and 41-5505(5), all carriers shall file annually with the Director the total number of residents, including spouses and dependents, covered during the previous calendar year as of December 31, 2008 under all health benefit plans issued in this state.

 
INDIVIDUAL:  
SMALL EMPLOYER:  
LARGE EMPLOYER:  
LONG TERM CARE (LTC):  
ADMINISTRATIVE SERVICES ONLY (ASO):  
ASSOCIATION HEALTH PLANS (AHPS):  
SPECIFIC DISEASE:  
HOSPITAL INDEMNITY:  
REINSURANCE BY WAY OF EXCESS LOSS/STOP LOSS:   
MEDICARE SUPPLEMENT:
MEDICARE PART D:   
Company Name:   
  If company address differs from address for the Annual Assessment Notice, please change.
Address:   
   
City, State and ZIP:  
Contact Person:   *
(Person we can call with questions regarding this filing.)
Contact Phone:   
(Direct Phone Number and Extension.)
Contact FAX:   
Contact Email:   
Officer's Name
and Title:  		 *
  * Required Fields
  By the electronic submission of this form the named officer of the carrier hereby affirms that the information provided herein was prepared under my supervision and that it is correct to the best of my knowledge and belief.