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Home > Insurance Division > Health Insurance Programs > IHC > Forms
IHC Program Forms
 
Standard Plans, Riders and Enrollment Forms (For Plans Issued on or After January 1, 2017)
Plans A/50, B, C, and D (Exhibit A) MS Word
HMO Plan (Exhibit B) MS Word
Explanation of Brackets Plans A/50 through D and HMO (Exhibit C) MS Word
Compliance and Variability Rider (Exhibit D) MS Word
Non-Group Enrollment Form MS Word 
Non-Group Conversion Form MS Word
 
Standard Plans, Riders and Enrollment Forms (For Plans Issued on or After January 1, 2016)
Plans A/50, B, C, and D (Exhibit A) MS Word
HMO Plan (Exhibit B) MS Word
Explanation of Brackets Plans A/50 through D and HMO (Exhibit C) MS Word
Compliance and Variability Rider (Exhibit D) MS Word
Non-Group Enrollment Form MS Word 
Non-Group Conversion Form MS Word
 
Reporting Forms
Certification of Compliance with Individual Health Coverage Plans Exhibit E (formerly Exhibit Q) (MS Word) UPDATED > Worksheet (MS Excel)
Identification of Plans Exhibit H (MS Word)
Loss Ratio report Exhibit J (PDF, rev. 2009)
Assessment Report Exhibit K (MS Word)
Enrollment Report - Quarterly Exhibit L – Part 1 (MS Excel)
Enrollment Report - Annual Exhibit L – Part 2 (MS Excel)
 
Filing Deadlines
*

NLT**

Exhibit Report Description N.J.A.C. Reference
A Feb. 14 Ex. L
Part 1 &
Part 2
(MS Excel)
Quarterly and Annual Enrollment Report 11:20-17.3
A Mar 1 Ex. E (MS Word) UPDATED > Worksheet (MS Excel) Certification of Compliance 11:20-3.2
B Apr 1 Ex. K (MS Word) Assessment report (premium data, enrollment data, adjusted net earned premium) 11:20-8.2 through 8.4
A May 1 *** Good-faith marketing of B&E Plans (for carriers offering B&E plans) 11:20-22.6
A May 15 Ex. L
Part 1 (MS Excel)
Quarterly Enrollment Report 11:20-17.3
A Aug 14 Ex. L
Part 1 (MS Excel)
Quarterly Enrollment Report 11:20-17.3
A Aug 15 Ex. J (PDF, rev. 2009)) Loss Ratio Report (and refund plan, if required) 11:20-7.4
A Nov 14 Ex. L
Part 1 (MS Excel)
Quarterly Enrollment Report 11:20-17.3
†† --------- *** Informational rate filings 11:20-6.3
Rules regarding the IHC Program are set forth in the New Jersey Administrative Code (N.J.A.C.) at 11:20, available through LexisNexis® free online at www.lexisnexis.com/njoal/
*This column indicates the frequency for filing the report.  A= annually.  B= biannually, in odd-numbered years. 
**NLT= no later than the date specified, unless the Board issues a bulletin extending a deadline.  The Board issues bulletins to carriers on the Board’s mailing list and posts bulletins to the Board’s website.
***There is no form; the rules specify the information that must be submitted.
Exhibit E also must be filed before marketing, issuing or renewing any standard policy form.
These reports must be filed prior to using the rates; rates cannot be stated for a period exceeding 12 months. For more information, see the Common Rate Filing Questions under the Rate Filing Resources for Carriers section at www.state.nj.us/dobi/lifehealthactuarial/rateinfo/.

 
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New Jersey Department of Banking and Insurance