FORM 1024A (ED: 6/28/99)
Date:
ARIZONA
INSURER RATE FILING
ADOPTION OF RATE SERVICE ORGANIZATION
PROSPECTIVE LOSS COSTS
REFERENCE FILING ADOPTION FORM
1. INSURER NAME
ADDRESS
PERSON RESPONSIBLE FOR FILING
TITLE
TELEPHONE #
2. INSURER NAIC #
3. LINE OF INSURANCE
4. RATE SERVICE ORGANIZATION
5. RATE SERVICE ORGANIZATION REFERENCE FILING #
6. The insurer named in number 1 above hereby declares that it is a member of the rate service organization, named in
number 4, for this line of insurance. The rate service organization has filed prospective loss costs (PLC) on behalf of its
member insurers in Arizona with the Director of the Arizona Department of Insurance (ADOI). Therefore, the insurer
hereby files, pursuant to A.R.S. § 20-385(A), its lost cost adjustment (LCA) and lost cost modification factors (LCMF) to
be used in the development of the loss cost multiplier (LCM) to be applied to the PLCs filed on the insurer’s behalf by the
rate service organization. The insurer’s rates will be the product of the PLC and the LCM(s) as developed from the
insurer’s LCA and LCMF.
7. PROPOSED RATE LEVEL CHANGE %
EFFECTIVE DATE
8. PRIOR RATE LEVEL CHANGE %
EFFECTIVE DATE
9. ATTACH “SUMMARY OF SUPPORTING INFORMATION FORM,” FORM 1024B
(Use a separate FORM 1024B for each insurer-selected LCM.)
10. CHECK ONE OF THE FOLLOWING:
Pursuant to A.R.S. § 20-385(A), the insurer hereby files to have its LCA and LCMF and any applicable
expense constant apply to future PLC revisions of the rate service organization for this line of insurance if the
insurer’s LCA and LCMF do not change. (If the LCA and LCMF change, the insurer is required to file the
new LCA and LCMF.) The insurer’s rates will be the product of the rate service organization’s PLC and the
insurer’s LCM as developed from the insurer’s LCA and LCMF. The rates that result from the insurer’s LCM
and the rate service organization’s PLC will apply to policies written on and after the effective date specified
by the rate service organization in its filing with the ADOI.
The insurer hereby files to have its LCM as developed from its LCA and LCM apply only to the current rate
service organization’s filing referenced above in number 5.
