N.M. Admin. Code § 13.18.2.31
Company Code___________________________________________________________
Company Name___________________________________________________________
Creditor Name___________________________________________________________
This deviation request form must be completed separately for each plan of credit life or credit disability insurance written by the creditor or group of creditors requesting the deviation. Experience of accounts may be combined only within the same plan of benefits and class of business. If experience of accounts is combined, attach a list of those included.
Based on the Experience Period commencing _____________________ and ending ___________________.
(month/day/year) (month/day/year)
Class of Business:
Plan of Benefits: () Credit Life, Death Benefits Only
() Credit Disability
_____ days
_____ RETRO _____ NON RETRO
N.M. Admin. Code § 13.18.2.31