The following format shall be used for reporting loss ratio experience:
MEDICARE SUPPLEMENT HEALTH CARE SERVICE PLAN CONTRACT EXPERIENCE EXHIBITFor the year ended December 31, 20__. For the State of California.Of the ____ health care service plan. Address (City, State, and Zip Code) ____ Person Completing this Exhibit ____ To be filed by June 30th following the filing under Section 1358.14 of the Health and Safety Code.
Costs for Health Care Services
Prepaid or
Percentage
Periodic
of Prepaid
Charges
or Periodic
Classification
Earned
Amount
Charges Earned
Experience on Individual Plan Contracts
1. _____ Contracts issued _____ through 20__
_____ Reporting State
_____ Nationwide
2. _____ Contracts issued _____ after 20__
_____ Reporting State
_____ Nationwide
Experience on Group Plan Contracts
1. _____ Contracts Issued _____ through 20__
_____ Reporting State
_____ Nationwide
2. _____ Contracts Issued _____ after 20__
_____ Reporting State
_____ Nationwide
The undersigned officer hereby certifies that the company named above has complied with the requirements contained in the federal Omnibus Budget Reconciliation Act of 1987, Section 4081.
Signature
Title and name (please type)