11 NCAC 10 .1207 FORM(S) QUESTIONNAIRE

All Property and Casualty Insurance Companies shall submit the following information with all forms filings on a form prescribed by the commissioner:

(1) name of the filer;

(2) Federal Employer's 11 Digit Number;

(3) filer's file number;

(4) program title;

(5) line(s) of insurance;

(6) how many new forms and/or revised forms are being filed;

(7) list all old form(s) being withdrawn and department file number(s);

(8) explain the purpose(s) of this filing;

(9) list the states where this filing has been made;

(10) action taken by domiciliary state if form has been filed in that state;

(11) list the states that have approved this filing;

(12) list the states that disapproved this filing and reason(s) for disapproval;

(13) copies of all required modifications referred to in Paragraph (12) of this Rule;

(14) if the filing is similar or identical to a filing made with the N.C. Department of Insurance by a licensed bureau or licensed rating organization, complete the following:

(a) name of affiliated bureau or rating organization;

(b) name of bureau or rating organization program;

(d) are you a member, subscriber or service purchaser.

(15) if the filing is similar or identical to a filing made with the N.C. Department of Insurance by a licensed insurance company in North Carolina, give the N.C. Insurance Department file number and approval date. Also, describe the difference(s) if any, between your form(s) and those of the previously approved program;

(16) computer printed declarations pages should be completed in "John Doe" fashion;

(17) proposed effective date and rule of implementation;

(18) a certification of the accuracy of the filing by an officer of the company or head of the filings department.

History Note: Authority G.S. 58-2-40; 58-2-190; 58-3-150; 58-41-50;

Eff. January 1, 1989;

Pursuant to G.S. 150B-21.3A, rule is necessary without substantive public interest Eff. January 3, 2017.