ࡱ> -/,q` (bjbjqPqP *::(  L$ $ $ $ $ $ $ $ p r r r ; $hjf$ $ $ $ $ $ $ D D D $ $ $ p D $ p D D D $  @*f 4 D d 0LD D D D $ $ D $ $ $ $ $ D $ $ $ L$ $ $ $  D  EXHIBIT J Loss Ratio Report Form ӣƵ Individual Health Coverage Program Reporting Year ________, for the Preceding Calendar Year Ending December 31, _____________ Name of Carrier: ___________________________________ NAIC # _______________ Address: ________________________________________________________________ ________________________________________________________________________ Carriers shall complete and file a separate Report Form for each affiliate. Note: Read the corresponding regulation, N.J.A.C. 11:20-7, before you complete this Report. A. Net Earned Premium for Standard Health Benefits Plans $ __________ B. Total Losses Incurred (1-2-3+4+5+6) = $ __________ 1. Claims paid during the preceding calendar year regardless of the year incurred; $ __________ 2. Residual reserve set on June 30 of the preceding calendar year for claims incurred prior to January 1 of the preceding calendar year; $ __________ 3. Claims paid from January 1 through June 30 of the preceding calendar year for claims incurred prior to January 1 of the of the preceding calendar year as reported in the preceding calendar years loss ratio report; $ __________ 4. Claims paid from January 1 through June 30 of the reporting year for claims incurred prior to January 1 of the reporting year; $ __________ 5. Residual reserve for claims incurred prior to January 1 of the reporting year, not paid as of June 30 of the reporting year; $ __________ 6. Pro-rata share of the reimbursable net paid loss assessment paid by the carrier during the preceding calendar year pursuant to N.J.A.C. 11:20-2.17; [i x (ii ( iii)] = $ __________ i. Total net paid loss assessment $ __________ ii. Net earned premium for standard health benefits plans $ __________ iii. Net earned premium for all health benefits plans $ __________ C. Loss Ratio (B ( A) = ________ (If less than 75%, fill out D and E below) D. Amount entered on line B ( .75 = $ __________ E. Amount to be refunded to policy or contract holders (A - D) = $ __________ If the amount entered on line C is less than 75%, you must attach to this Report a refund plan that conforms with N.J.A.C. 11:20-7.5. Please submit this form and a refund plan to the address listed in N.J.A.C. 11:20-2.1(h). I certify that the above information is accurate, complete and has been prepared in accordance with N.J.S.A. 27A-9e(1) and (2) and N.J.A.C. 11:20-7. ____________________________________ Actuarys Signature ____________________________________ Actuarys Name (Please print clearly) ____________________________________ Title Date ____________________________________ Telephone Number ____________________________________ Facsimile Number  %( h<5>* jh<h< h<5  !OP|D 8 9 c ( ] 4 j $ $a$($ O R/X|MN/0 7c&'((/ =!"#$% L@L Normal5$7$8$9DH$CJ_HmH sH tH DA@D Default Paragraph FontVi@V  Table Normal :V 44 la (k@(No List (  !OP|D89c(]4j$OR/X|MN/ 0 7 c  & ' * 000000000000000000000000000000000000000000000000000000000000000 * I0I0$( $ ( ( ' * ' * <* @HP LaserJet 2100 PCL6LPT1:winspoolHP LaserJet 2100 PCL6HP LaserJet 2100 PCL64C odXXLetterDINU"4O HP LaserJet 2100 PCL64C odXXLetterDINU"4O d ( @UnknownG: Times New Roman5Symbol3& : Arial"hrFrF%~ ~ $xx4# # 2HX?2 EXHIBIT J IHC / SEH Ellen DeRosaOh+'0|   , 8 D P\dlt EXHIBIT J IHC / SEHNormalEllen DeRosa2Microsoft Office Word@F#@&T@4Y*f@4Y*f~ ՜.+,0 hp  NJDOBI#   EXHIBIT J Title  !"#%&'()*+.Root Entry F((*f01TableWordDocument*SummaryInformation(DocumentSummaryInformation8$CompObjq  FMicrosoft Office Word Document MSWordDocWord.Document.89q