N.H. Code Admin. R. Ins 5001 app B - STATE OF NEW HAMPSHIRE INSURANCE DEPARTMENT

CONSENT TO RATE FORM

Must be accompanied by declarations page showing name, location and address.)

NAMED INSURED AND MAILING ADDRESS

INSURANCE COMPANY AND MAILING ADDRESS

Policy Number_____________________

Policy Term_______________________

REASON(S) FOR EXCEPTION TO FILED RATE(S) - RSA 412:16X:

Describe exposure(s) or any substandard, unusual or hazardous conditions which necessitates the use of a rate or premium not filed with the Department. Include any underwriting information in support of the proposed rating. Reasons that merely refer to a policyholder's inability to obtain coverage at standard rates, or comments that essentially equate to "class of risk" are not acceptable.

_____Unusual hazard involved

_______Unfavorable loss experience

______Other

Explanation of above reason(s)

Premium at filed rate(s)______________

Premium at Consent Rate(s)_____________

I HEREBY CERTIFY AND I UNDERSTAND THAT THE PREMIUM CHARGE FOR THIS POLICY (ENDORSEMENT) IS NOT STANDARD.

____________________________ ______________________________

Policyholder Signature Date

____________________________

Title

The signature by the policyholder or an authorized representative of the policyholder (NOT the insurance agent) must be made after this form has been completed.

Available at https://www.nh.gov/insurance/pc/documents/consenttorate.pdf

Notes

N.H. Code Admin. R. Ins 5001 app B

State regulations are updated quarterly; we currently have two versions available. Below is a comparison between our most recent version and the prior quarterly release. More comparison features will be added as we have more versions to compare.


No prior version found.