N.H. Admin. Code Ins, ch. Ins 5000, pt. Ins 5001, app B
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
N.H. Admin. Code Ins, ch. Ins 5000, pt. Ins 5001, app B