N.J. Admin. Code § Tit. 11, ch. 4, subch. 56, app B
Current through Register Vol. 56, No. 19, October 7, 2024
| Self-Funded MEWA Loss Ratio Report Form |
| Small Employer Business |
| Reporting Year (Year in which this report was prepared) ............ |
| For Preceding Calendar Year Ending December 31, .................... |
| Name of MEWA: ............................................... |
| Address of MEWA: ............................................ |
| 1. Premiums ................... |
| 2. Claims (a. + b.-c. + d.-e.) ................... |
| a. ................... |
| b. ................... |
| c. ................... |
| d. ................... |
| e. ................... |
| 3. Loss Ratio (2./1.) ................... |
| 4. Dividends (.75 x 1.)- 2. ................... |
| Signature of Preparer Date ........................ | Date ................ |
| Name of Preparer Title ............................ | Title ............... |
| Address .................................................................... |
| Telephone Number ........................................................... |
| 1. | Premiums are total earned premiums for small employer business, before |
| any dividends or credits applicable to prior year's Loss Ratio Reports. |
| 2. | Claims for small employer business are equal to: |
| a. | claims paid in the preceding calendar year regardless of year |
| incurred; plus |
| b. | claims paid from January 1 to June 30 of the reporting year for |
| claims incurred prior to January 1 of the reporting year; less |
| c. | claims paid from January 1 through June 30 of the |
| preceding calendar year for claims incurred prior to January 1 of |
| the preceding calendar year (as reported in the preceding |
| year's Loss Ratio Report); plus |
| d. | a residual reserve equal to 3.3 percent of a. + b.-c.; less |
| e. | a residual reserve (as reported in the preceding year's Loss |
| Ratio Report). |
| 3. | Loss Ratio is the quotient, to the nearest. 1 percent, of the Claims |
| dividend by the Premiums (2. divided by 1.) |
| 4. | Dividends are 0 if the amount on Line 3 is 75.0% or greater. Otherwise, |
| dividends are equal to (75% of Line 1.) minus Line 2. |
N.J. Admin. Code Tit. 11, ch. 4, subch. 56, app B