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["WAC 284-66-203"]
["Last modified 03/21/2025"]
["Purpose"]
["The WAC 284-66-203(6) format is for filing your Annual Filing of Premium Rates and Experience for your Standardized plans only. "]
["The form found in WAC 284-55-210 should be used for reporting any prestandardized experience."]
[]
["Instructions"]
["1. Create a separate sheet for each plan form by copying the WAC 284-66-203 format as many times as needed."]
["a. If you fill out the tables below, you can click on the \"Generate Worksheets\" button and it will automatically generate the worksheets for each plan, type, and form no."]
["b.  You may rename sheets as needed."]
["2. Experience for policies issued during the reporting year should be added as Policy Duration 0"]
["3. Do not provide any information in this workbook except for the experience incurred in the reporting year in the format provided on the WAC 284-66-203 tabs."]
["4. After finalizing, you should submit both a pdf and excel version of this file to the corresponding SERFF filing."]
["5. Current rates must be filed as a separate PDF."]
[]
["Company Name","Reporting Year","Address","NAIC Group Code","*NAIC Company Code","**CIC Code"]
[]
[]
["Plan","Type","Form No."]
[]
[]
[null,null,null,null,"<<<<<Drag the table down as needed"]

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[]
[]
[null,"Annual Filing of Premium Rates and Experience\nTo be filed on or before May 31 of each calendar year"]
[]
[null,"Experience from January 1 to December 31, of ",null,null,null,null,null,null,"(year)","reported by duration for all "]
[null,"business from inception to December 31, 20"]
[null,"Company Name"]
[]
[null,"Address"]
[]
[null,"NAIC Group Code",null,null,null,null,"*NAIC Company Code",null,null,"**CIC Code"]
[]
[]
[]
[null,"Plan",null,null,null,null,"Type",null,null,"Form No."]
[]
[]
[null,"Premium Rates [Attach schedule]"]
[]
[null,"Insurance is [check one]",null,null,null,null,"Group",null,"or, Individual"]
[]
[null,"Washington Experience. [Show all experience for the reported calendar year (separately for each duration).]"]
[]
[null,"Policy\nDuration",null,null,null,null,"Incurred Losses",null,"Earned Premiums",null,"Loss Ratios",null,"Claim Reserves"]
[null,0]
[null,1]
[null,2]
[null,3]
[null,4]
[null,5]
[null,6]
[null,7]
[null,8]
[null,9]
[null,10]
[null,11]
[null,12]
[null,13]
[null,14]
[null,"15+"]
[]
[null,"I hereby certify that I have supervised the preparation of this experience exhibit, that all durational information has been furnished, and to the best of my knowledge, the data is accurate and is in compliance with RCW 48.66.150 and WAC 284-66-203."]
[]
[]
[null,"Signature of Officer",null,null,null,null,null,null,"Date"]
[]
[]
[null,"Name and Title of Officer",null,null,null,null,null,null,"Prepared by"]
[]
[]
[null,"Phone Number",null,null,null,null,null,null,"Phone Number"]
[]
[]
["* NAIC Code is the same as you CoCode on the Companies and Contact tab.  "]
["**CIC code is the same as your WAOIC #.  If you do not have this number, you may contact the helpdesk at "]
["    360-725-7111 or leave it blank"]