Code of Maine Rules › 02 - DEPARTMENT OF PROFESSIONAL AND FINANCIAL REGULATION › 031 - BUREAU OF INSURANCE › Chapter 220 - CREDIT LIFE AND HEALTH INSURANCE › Appendix 031-220-A

Current through 2024-29, July 17, 2024
Forms L1, L2, L3, and L4 must be completed for each case
				  involving credit life insurance. Forms D1, D2, D3 and D4 must be completed for
				  each case involving credit disability insurance. Copies of all forms are
				  attached. Experience reports shall be submitted in electronic format.
				  Electronic versions of the forms are available on the Bureau of insurance web
				  site at
www.maineinsurancereg.org
. All reports
				  must be submitted on or before June 1 each year.
CREDIT LIFE INSURANCE SUMMARY REPORT - STATE OF MAINE
FORM L1
COMPANY ________________
NAIC #
____________
CASE ___________________________________________YEAR
				  ENDING_________________
Classes of Business (Check all that apply):
[ ] (a) credit unions [ ] (e) other sales finance
[ ] (b) commercial & savings banks [ ] (f) production
				  credit associations; bank
[ ] (c) finance companies agricultural loans
[ ] (d) motor vehicle dealers [ ] (g) all others
Mode of Premium Payment:
[ ] Outstanding Balance(Monthly Premium) [ ] Revolving
				  Account
[ ] Single Premium [ ] Fixed Monthly Premium
Plan of Benefits (Check one or both): [ ] Decreasing [ ]
				  Non-Decreasing
MONTHLY PREMIUM PER $1,000
__
Single Life
__ ___
Joint Life
____
Present Case Rate __________________
				  __________________
Calculated Case Rate (from
Form L2, Line J) __________________ __________________
Case Rate to be Used __________________
				  __________________
Effective Date of Last Rate Revision* __________________
				  __________________
Effective Date of New Rates or Renewal
Date of Present Rates __________________
				  __________________
The information above and on Forms L2, L3 and L4 attached is
				  true to the best of my knowledge and belief.
Signature (not required if filed electronically)
				  ______________________________________
Name _________________________________
(Type or Print)
Position ____________________________Telephone
				  _____________________________
Email ____________________________________
* Enter the date the rates were initially implemented if
				  there have not been any rate revisions.
CREDIT LIFE INSURANCE EXPERIENCE REPORT - STATE OF
				  MAINE
FORM L2
COMPANY _____________________________________NAIC #
				  ____________
CASE______________________________________________________________
MAINE EXPERIENCE LAST THREE
				  YEARS
SINGLE ____JOINT_______ TOTAL
(from Form L3)
A. Earned Premium at Prima Facie Rate __________ ___________
				  ____________
B. Incurred Losses _____________ ______________
				  _________________
C.
*
1. Number of Life
Years Covered _______________ _____________
				  _____________
2. Number of Claims Incurred ___________ ____________
				  ______________
D. Credibility Factor (from table)
(Use TOTAL factor for both SINGLE and
				  JOINT)__________________
E. Prima Facie Rate .50 .84 XXX
F. Prima Facie Claim Cost .315 .63 XXX
G. Expected Losses [A x F/E] _______________ ________________
				  _________________
H. Actual/Expected Ratio [B/G]
(Use TOTAL ratio for both SINGLE and
				  JOINT)_________________
I. Deviation [D x (H - 1) x F] ___________ _______________
				  XXX
J. Deviated Rate [E + I] ___________ ______________ XXX
* Complete either C.1. or C.2., as elected in writing
				  pursuant to Section
				  13 of Rule Chapter 220.
CREDIT LIFE INSURANCE EXPERIENCE REPORT - STATE OF
				  MAINE
FORM L3
COMPANY __________________________NAIC #
				  _____________________
CASE____________________________________________________________
A. Earned Premium at
Prima Facie Rate _____________ ________________ _____________
				  ________________
B. Incurred Losses ____________ ____________ ____________
				  _____________
C.
*
1. Number of Life
Years Covered __________________ ________________
				  ______________ ________________
2. Number of Claims
Incurred _______________ ______________ _____________
				  _____________________
A. Earned Premium at
Prima Facie Rate ________________ ____________
				  ________________ ______________
B. Incurred Losses ______________ ______________ ____________
				  __________________
C.
*
1. Number of Life
Years Covered ______________ _______________ ________________
				  _________________
2. Number of Claims
Incurred ________________ ________________ ______________
				  _____________________
* Complete either C.1. or C.2., as elected in writing
				  pursuant to Section
				  13 of Rule Chapter 220.
CREDIT LIFE INSURANCE EXPERIENCE REPORT - STATE OF
				  MAINE
FORM L4
COMPANY _________________________________NAIC #
				  ____________
CASE ____________________________________________YEAR
				  ENDING________________
1. Actual Earned Premiums
Single
				  Joint
a. Gross premium written (before deduction for
Dividends and Experience Rating Credits) _________________
				  __________________
b. Refunds on Termination ____________________
				  ____________________
c. Net [a - b] ________________________
				  ________________________________
d. Premium reserve, beginning of period ___________________
				  _______________
e. Premium reserve, end of period ______________________
				  ___________________
f. Actual Earned Premiums [c+d-e] ________________
				  _______________________
2. Prima Facie Earned Premiums
a. Insured Balance [See Section 9.D(3) of Rule]
				  ___________________ ________________
b. Earned Premium at prima facie rate
[Single: (a x .00050); Joint: (a x .00084)] _________________
				  __________________
3. Incurred Claims
a. Claims paid __________________
				  _______________________
b. Unreported claims, beginning of period _________________
				  _______________________
c. Unreported claims, end of period ____________________
				  ____________________
d. Claim reserve, beginning of period ___________________
				  ________________________
e. Claim reserve, end of period ______________________
				  __________________________
f. Incurred claims (a - b + c - d + e)
				  _______________________ _____________________
4. Loss Ratio
a. Actual loss ratio (3f / 1f) _______________________
				  ________________________
b. Loss ratio at prima facie rate (3f / 2b)
				  _______________________ _____________________
5. State basis for incurred but unreported
				  claims:_________________________________
_____________________________________________________________________
_____________________________________________________________________
CREDIT DISABILITY INSURANCE EXPERIENCE REPORT - STATE OF
				  MAINE
FORM D1
COMPANY ___________________________NAIC # ____________
CASE _______________________YEAR
				  ENDING_________________________
Classes of Business (Check all that apply):
[ ] (a) credit unions [ ] (e) other sales finance
[ ] (b) commercial & savings banks [ ] (f) production
				  credit associations; bank
[ ] (c) finance companies agricultural loans
[ ] (d) motor vehicle dealers [ ] (g) all others
Mode of Premium Payment:
[ ] Single Premium [ ] Revolving Account
[ ] Outstanding Balance (Monthly Premium) [ ] Fixed Monthly
				  Premium
DEVIATION RATIO
Present Deviation Ratio for Case
				  ______________________________
Calculated Deviation Ratio (from Form D2, Line O)
				  ______________________________
Deviation Ratio to be Used
				  ______________________________
Effective Date of Last Rate Revision*
				  ______________________________
Effective Date of New Rates or Renewal Date of
Present Rates ______________________________
The information above and on Forms D2, D3 and D4 attached is
				  true to the best of my knowledge and belief.
Signature (not required if filed electronically)
Name ______________________________
(Type or Print)
Position
				  _________________________________Telephone_____________________________
Email ______________________________
* Enter the date the rates were initially implemented if
				  there have not been any rate revisions.
CREDIT DISABILITY INSURANCE EXPERIENCE REPORT - STATE OF
				  MAINE
FORM D2
COMPANY ______________________________________NAIC #
				  ____________
CASE____________________________________________________________
MAINE EXPERIENCE LAST THREE YEARS
A. Earned Premium at Prima Facie
				  Rate_________________________________________________________________________
B. Incurred Losses
				  ________________________________________________________________________
C. Imputed Investment Income
				  ______________________________________________________________________
D. Incurred Loss Ratio at Prima Facie [B/(A+C)]
				  ______________________________________________________________
E.
*
1. Number of Life Years
				  Covered_____________________________________________________________________
2. Number of Claims
				  Incurred________________________________________________________________________
DEVIATION
F. Credibility Factor (from table) XXX XXX_________
G Average Term of Indebtedness __________
				  ____________XXX
H. Prima Facie Rate ____________________
				  _________________XXX
I. Benchmark Loss Ratio _________________
				  _______________XXX
J. Prima Facie Claim Cost [HxI] ___________
				  ________________XXX
K Expense Loading [H-J] _______________
				  ______________XXX
L. Plan Ratio [D/I] _____________________
				  _________________XXX
M. Adjusted Plan Ratio [ {(L - 1) X F } + 1 ________________
				  ________________XXX
N. [(MxJ)+K] _________________ ____________________XXX
O. [N/H] ___________________ ______________________XXX
P. [OxA] ____________________ + _____________________=
Q. Calculated Deviation Ratio [ P / A ] XXX XXX
* Complete either E.1. or E.2., as elected in writing
				  pursuant to Section
				  13 of Rule Chapter 220.
CREDIT DISABILITY INSURANCE EXPERIENCE REPORT - STATE OF
				  MAINE
FORM D3
COMPANY _____________________________NAIC #
				  ____________
CASE _____________________________YEAR
				  ENDING_______________
1. Actual Earned Premiums
RETRO
NON-RETRO
a. Gross premium written (before deduction for
dividends and experience rating credits) _________________
				  ______________________
b. Refunds on termination ___________________________
				  _______________________
c. Net [a - b] _____________________________
				  ______________________________
d. Premium reserve, beginning of period ______________
				  _________________________
e. Premium reserve, end of period _______________________
				  ____________________
f. Actual earned premiums [c +d - e] ____________________
				  _____________________
2. Prima Facie Earned Premiums (from D4) _________________
				  ____________________
3. Imputed Investment Income [(1d + 1e) x .03]
				  ________________ __________________
4. Incurred claims ___________________
				  __________________________
a. Claims paid _____________________
				  __________________________
b. Unreported claims, beginning of period
				  _____________________ ___________________
c. Unreported claims, end of period ___________________
				  _______________________
d. Claim reserve, beginning of period ___________________
				  ______________________
e. Claim reserve, end of period _________________
				  ______________________
f. Incurred claims (a - b + c - d + e) __________________
				  ___________________
5. Loss Ratio
a. Actual loss ratio (4f / 1f) _____________________
				  ______________________
b. Loss ratio at prima facie rate (4f / line 2)
				  ___________________ __________________
CREDIT DISABILITY INSURANCE EXPERIENCE REPORT - STATE OF
				  MAINE
FORM D4
COMPANY ________________________NAIC #
____________
CASE ___________________________YEAR ENDING
RETRO
NON-RETRO
Actual Earned
Premiums _
Col
							 1
Deviation
Ratio _
Col. 2
Prima Facie Earned Premium
Col.
1 /
Col
. 2 _
Col. 3
Actual Earned
Premiums _
Col
							 1
Deviation
Ratio _
Col. 2
Prima Facie Earned Premium
Col.
1 /
Col
. 2 _
Col. 3
A. Earned premiums at prima facie rate
_____________
1.000
______________
______________
1.000
______________
B. Earned premiums at other than prima facie rates:
1. ___________
_____________
______________
1. _____________
_____________
______________
2. ___________
_____________
______________
2. _____________
_____________
______________
3. _________
__________
___________
3. __________
___________
___________
4. _________
__________
___________
4. __________
___________
___________
5. ________
__________
___________
5. __________
___________
___________
6. ________
__________
___________
6. __________
___________
___________
Totals
___________ To agree with Form D3, Line 1f
xxx
______________ To Form D3, Line 2
____________ To agree with Form D3, Line 1f
xxx
______________ To Form D3, Line 2