Figure 47 - Texas Small Employer Actuarial Certification

Figure 47 - Annual small employer health benefit plan actuarial certification

LAH334 | 0126
Form Number 1212 CERT ACTUARIAL

Texas Insurance Code Chapter 1501 and 28 TAC §26.20

All fields marked with * are required and must be filled.
Company Name*
NAIC Number*
TDI Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Reporting year*
Choose the year that represents the information being submitted. It most cases, it is the previous calendar year.
Contact Name
Title
Phone Number
Please enter a valid phone number.
Email*
example@example.com
May TDI release this email address?*

YesNo
Choose the applicable statement:*

The undersigned qualified actuary certifies that the underwriting and rating methods of the named small employer carrier 1) comply with accepted actuarial principals and practices, 2) are uniformly applied to each small employer health benefit plan covering a small employer (as these terms are defined in Insurance Code 1501), and 3) comply with the provisions of the Insurance Code Chapter 1501, Subchapter E and 28 TAC §§26.1 - 26.27.The undersigned qualified actuary certifies that the underwriting and rating methods of the named small employ carrier do not comply with the underwriting and rating provisions set forth above. (Respondent must provide an explanation identifying the areas of noncompliance and the carrier's proposed actions to correct such noncompliance in the field that appears below.)
Explanation identifying areas of noncompliance and proposed actions to correct:
Documentation for Rating Methodology, rating practices, and underwriting practices

The named carrier has in its possession or has been provided a complete and detailed description of the applicable rating methodology, including, but not necessarily limited to, rating practices and renewal underwriting practices. Such documentation includes information that demonstrates that the applicable rating methods and practices are based on commonly accepted actuarial assumptions and are in accordance with sound actuarial principles.
Additional comments/qualifications:
Name*
Title*
Phone Number
Please enter a valid phone number.
Should be Empty:

Figure 47 - Annual small employer health benefit plan actuarial certification