# COMAR Title 31 — Maryland Insurance Administration

## Subtitle 10 — Health Insurance — General

### Chapter 06 — Standards for Medicare Supplement Policies

#### Regulation .20 Form for Reporting Multiple Policies.

*COMAR 31.10.06.20*

The following form is to be used in making reports of multiple policies in accordance with the requirements of Regulation .17 of this chapter:

(a)3
            (b)4
            (c)
            (d)
            (e)
            (f)
            (g)
            (h)
            (i)
            (j)
            (o)5
          
          
            Year
            Earned Premium
            Factor
            (b) × (c)
            CumulativeLoss Ratio
            (d) × (e)
            Factor
            (b) × (g)
            CumulativeLoss Ratio
            (h) × (i)
            Policy YearLoss Ratio
          
        
        
          
            1
            
            2.770
            
            0.442
            
            0.000
            
            0.000
            
            0.4
          
          
            2
            
            4.175
            
            0.493
            
            0.000
            
            0.000
            
            0.55
          
          
            3
            
            4.175
            
            0.493
            
            1.194
            
            0.659
            
            0.65
          
          
            4
            
            4.175
            
            0.493
            
            2.245
            
            0.669
            
            0.67
          
          
            5
            
            4.175
            
            0.493
            
            3.170
            
            0.678
            
            0.69
          
          
            6
            
            4.175
            
            0.493
            
            3.998
            
            0.686
            
            0.71
          
          
            7
            
            4.175
            
            0.493
            
            4.754
            
            0.695
            
            0.73
          
          
            8
            
            4.175
            
            0.493
            
            5.445
            
            0.702
            
            0.75
          
          
            9
            
            4.175
            
            0.493
            
            6.075
            
            0.708
            
            0.76
          
          
            10
            
            4.175
            
            0.493
            
            6.650
            
            0.713
            
            0.76
          
          
            11
            
            4.175
            
            0.493
            
            7.176
            
            0.717
            
            0.76
          
          
            12
            
            4.175
            
            0.493
            
            7.655
            
            0.720
            
            0.77
          
          
            13
            
            4.175
            
            0.493
            
            8.093
            
            0.723
            
            0.77
          
          
            14
            
            4.175
            
            0.493
            
            8.493
            
            0.725
            
            0.77
          
          
            15+6
            
            4.175
            
            0.493
            
            8.684
            
            0.725
            
            0.77
          
          
            
            
            
            ________
            
            ________
            
            ________
            
            ________
            
          
          
            Total:
            
            (k):
            
            (l):
            
            (m):
            
            (n):

The purpose of this form is to report the following information on each resident of this state who has in force more than one Medicare supplement policy or certificate. The information is to be grouped by individual policyholder.

FORM FOR REPORTINGMEDICARE SUPPLEMENT POLICIES
          
        
        
          
            Company name:
            ________________________________________
          
          
            Address:
            ________________________________________
          
          
            
            ________________________________________
          
          
            Phone Number:
            ________________________________________
          
          
            
            Due: March 1, annually

Policy andCertificate #
            Date ofIssuance