Policy Form and Rate Filing Checklists

Filing Guidance Notices

Property and Casualty

 2006-A: Compliance with M.G.L. 175, § § 18 and 192 
 2006-B Excess/Umbrella Endorsements 
 2006-D: Lead Poisoning & Residential Property Disclosure Statement 
 2007-A: Updates to Policy Form Review Checklists 
 2007-B: Interline Filing Instructions 
 2008-A: Addendum to Bulletin 2008-04 
 2008-C: Private Passenger Motor Vehicle Rate Filings 
 2008-E:Premium Modifications For Motor Vehicle Safety Devices or Features 
 2008-F:Anti-Theft Systems or Devices Used to Discount Premiums for Certain Motor Vehicles 
 2008-G:Adoption of Advisory Rates for Automobile Insurance Policies 
 2008-H:Private Passenger Motor Vehicle Rate/Rule Filings 
 2008-I: Warranty Reimbursement Insurance Policies 
 2009-B Designation of High-Theft Motor Vehicles Effective August 1, 2009 
 2009-D Changes to Regulation 211 CMR 94.00 - Pre-Insurance Inspection of Private Passenger Motor Vehicles 
 2009-H Filing of Interline Forms and Rules 
 2009-I Supplemental Filing Document to be Submitted with Private Passenger Motor Vehicle Rate/Rule Filings for Policies Effective on or after April 1, 2010 
 2010-B Rate and Form Filing Requirements for Insuring Low-Speed Private Passenger Motor Vehicles 
 2010-C Required Filing Documents to be Submitted with Private Passenger Motor Vehicle Rate/Rule Filings for Policies Effective on or after July 1, 2010 
 2010-D Filing Requirements for Private Passenger Motor Vehicle Rate Symbol Assignments Effective 8/1/2010 
 2010-E High Theft Motor Vehicle List Effective 8/1/2010 
 2011-A General Liability - Claims Made Options 
 2011-B 2012 High Theft Vehicle List for Private Passenger Auto 
 2012-A 2013 High Theft Vehicle List for Private Passenger Auto 
 2013-A Submitting Commercial Automobile Insurance Rate Filings in Massachusetts 
 2013-B 2014 High Theft Vehicle List for Private Passenger Auto 
 2014-A High Theft Vehicle List for Private Passenger Auto Effective August 1, 2014  
 2014-B Required Filing Documents to be Submitted with Private Passenger Motor Vehicle Rate/Rule Filings for Policies Effective on or after April 1, 2015  file size 1MB
 2015-A High Theft Vehicle List for Private Passenger Auto Effective August 1, 2015 
 2016-A High Theft Vehicle List for Private Passenger Auto Effective August 1, 2016 
  Filing Guidance Notice 2016-B (Travel Insurance Coverage)  
2017-A High Theft Vehicle List for Private Passenger Auto Effective August 1, 2017 

Life and Annuity

2006-C: Table of Guaranteed Values 
2006-E: Guaranteed Minimum Benefits 

Accident and Sickness

2009-C: Long-Term Care Insurance Rate Filings 

Health

2017-D (revised September 15, 2017): Factoring Federal Funding of Cost-Sharing Reduction (“CSR”) Payments in Filing of 2018 M.G.L. C. 176J Rates 
2017-D: Factoring Federal Funding of Cost-Sharing Reduction (“CSR”) Payments in Filing of 2018 M.G.L. C. 176J Rates 
2017-C: 2017 Filing Guidance Notice FPY Effective 01012018 - Policy Form and Rate Materials - Organization Contact List 
2017-B: 2017 Filing Guidance Notice FPY Effective 01012018 - Policy Form and Rate Materials - FAQs 
2017-A: 2017 Filing Guidance Notice FPY Effective 01012018 - Policy Form and Rate Materials 
2016-D: Rehabilitative and Habilitative Services and Devices within Insured Health Benefit Plans 
2016-C: Pediatric Vision and Dental Benefits for Merged Market Plans 
2016-B: Meaningful Access for Limited-English Proficient Speakers 
2016-A: Submission of Policy Form/Rate Materials Necessary for the Review of Health 
2015-D: Preventive Care and Out-of-Pocket Maximums within  
2015-C: Health Coverage (RBPO) Filing Guidance Notice  
2015-B: Rate Filing Materials for Rates Intended to Be Effective for Coverage Issued or Renewed in 2016  
2015-A: Submission of Policy Form Materials Necessary for the Review of Health Benefit Plans 
2013-L: Data Collection Tool              Data Collection Tool                                
2013-L: Submission of Additional Rate Filing Material for Rates Intended to Be Effective for Coverage Issued or Renewed in 2014 
 2013-K: Submission of Material to Illustrate Changes to Rating Factors in Rate Filings for Rates to be Effective in 2014 and 2015 
 2013-J: Dental Data Collection Tool          Dental Data Collection Tool 
 2013-J: Standard Worksheet to be Used With Dental Rate Filings Submitted for Dental Plans Proposed to be Offered as Exchange-Certified Stand-Alone Dental Plans 
 2013-I: Reflecting Reinsurance and Risk Adjustment in Small Group Health Insurance Filings for Rates Effective On and After January 1, 2014 FILING GUIDANCE 
 2013-H: Submission of Federally Required Rate Filing Justification 
 2013-G: Submission of Material to Support Calculated Actuarial Values 
 2013-F: Submission of Rate Filing Material on July 1, 2013 
 2013-E: Submission of Confidential Rate Filing Material to the Division of Insurance 
 2013-D: Services Provided by Physician Assistants 
 2013-C: Telemedicine Services 
 2013-B: Changes to Names of Agencies Responsible for Managed Care Practices 
 2013-A: Submission of Materials Necessary for the Review of Health Benefit Plans 
 2012-G:Reflection of ACA Costs in Small Group Health Insurance Rate Filings 
 2012-E: Rate Filings for New Products and Significant Changes to Existing Products 
 2012-D: Filings for Products that Include Rewards and/or Discounts 
 2012-C: Small Group Health Insurance Rate Filings - Administrative Expenses 
 2012-B Worksheets: PDF          Excel Version 
 2012-B: Standard Worksheet to be Used With Small Group Health Rate Filings Submitted for Rates Proposed to be Effective On and After October 1, 2012   
2012-A: Responses to Group Purchasing Cooperative Request for Proposals 
 2011-C: Small Group Health Insurance Rate Filings - Medical Loss Ratio 
 2010-D: SERFF PPACA Uniform Compliance Form 
 2010-A: Filing Rates and Changes to Rating Factors under 211 CMR 43.00 
 2009-G: Tiered Benefits Within Closed Network Health Plans 
 2009-B:Closed Network Health Plans 
 2009-A:Material Changes Required by 211 CMR 52.00 

Workers Compensation

Workers Compensation

2012-F: Submission of Deviation and Schedule Credit Plan Filings to be Effective on or After September 1, 2012 
2009-J:Repatriation Policy Guidance 

Workers' Compensation Forms PDF Version  Word Version   
Workers' Compensation Rate Deviation Abstract PDF Version  Word Version 
Workers' Compensation Rates PDF Version   
Workers' Compensation Deviation Templates   Excel Templates 
Preferred Provider Arrangement – Annual Report filing form PDF Version  Word Version 

CHECKLISTS Base Checklists, Supplemental Checklists

Please refer to the System for Electronic Rate and Form Filing for the current editions of these Checklists. All Checklists are accessible under Requirements on the Filing Rules tab, and are available under their Types and Sub-Types of Insurance when creating filings.

If you have any questions please contact Sheri Cullen, Director of Policy Form Review at 617-521-7359 or at sheri.cullen@state.ma.us

Additional Checklists for Property and Casualty Products:

Lead Poisoning & Residential Property Disclosure Statement PDF Version 
Deviations for Group Marketing Plans for Automobile and Homeowners Insurance PDF Version 
Group Marketing Checklist   Word Version 
Application Spreadsheet For Group Marketing Plan   Excel Version  file size 1MB
Motor Vehicle Forms PDF Version  Word Version 
Motor Vehicle Rates PDF Version  Word Version 
Motor Vehicle Insurance Installment Plan Checklist PDF Version  Word Version 
Home Insurance Installment Payment Plan Checklist PDF Version  Word Version 
Pre-insurance private passenger motor vehicle inspection plans PDF Version  Word Version 
Rate Deviation Abstract PDF Version 

Checklists for Managed Care:

Health Maintenance Organizations  file size 1MB
 Insured Preferred Provider Plans 
 Insurance Companies 
 Provider Contracts 
 Initial Accreditation 
 Renewal Accreditation 
 Medicare Supplement Plan 
 Group Stand-Alone Dental and Vision 
 Individual Stand-Alone Dental and Vision 

Purchasing Groups and Risk Retention Groups

Annual Application for Registration as a Purchasing Group 
Application to Register a Risk Retention Group   

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