All Rate and Form Filings submitted to the Bureau of Insurance for review must be accompanied by the appropriate rate and/or form review checklists for the product being submitted. The checklists must be completed and must reference, for each requirement on the checklist, the location (i.e. form, page number, paragraph, etc.) of each standard in the filing.
If you have any questions about the Health and Life checklists, please contact Kim Jalbert, Senior Insurance Analyst, at Kimberly.Jalbert@maine.gov or call
The documents on this page are also available in hard copy by contacting the Bureau.
Non-QHP Requirements Checklists
Accident & Health Form Filing Requirements
- Group Accident Only (DOCX) - (H02G)
- Individual Accident Only (DOCX) - (H02I)
- Group Accidental Death & Dismemberment (DOCX) - (H03G)
- Individual Accidental Death & Dismemberment (DOCX) - (H03I)
- Blanket Accident and Sickness (DOCX) - (H04)
- Blanket Accident Only (DOCX) - (H04)
- Student Health Insurance - ACA Compliant (DOCX) - (H22)
- Group Specified Disease (DOCX) - (H07G)
- Individual Specified Disease (DOCX) - (H07I)
- Group Dental NON-Qualified (DOCX) - (H10G)
- Individual Dental NON-Qualified (DOCX) - (H10I)
- Group Disability Income (DOCX) - (H11G)
- Individual Disability Income (DOCX) - (H11I)
- Group Disability - Maine Tax Credit Qualified STD and LTD (DOCX) - (H11G.004 Other)
- Individual Paid Family Medical Leave (DOCX) - H11I.010
- Group Paid Family Medical Leave - PFML (DOCX) - (H11G.006)
- Maine DOL Paid Family Medical Leave Program (DOCX) - Revised 12/18/24
- Excess/Stop Loss (DOCX) - (H12G)
- Group Short Term Care (DOCX) (H13G)
- Individual Short Term Care (DOCX) (H131)
- Group Hospital Confinement Indemnity (DOCX) - (H14G)
- Individual Hospital Confinement Indemnity (DOCX) - (H14I)
- Group Hospital/Surgical/Medical Expense (DOCX) - (H15G)
- Large Group Major Medical (DOCX) - (H16G)
- Individual Major Medical SHORT-TERM, LIMITED-DURATION (DOCX) - (H16I.004)
- Short-term, Limited-duration Policy - Summary of Plan Benefits (DOC)
- Group Indemnity Other Than Hospital (DOCX) - (H23G)
- Individual Indemnity Other Than Hospital (DOCX) - (H23I)
- Group Similar Supplemental to Major Medical (DOCX) (H25G)
- Large Group HMO-POS (DOCX) - (HOrg02G)
- Group & Individual Long Term Care/Partnership (DOCX) - (LTC03G and LTC03I)
- Group Medicare Supplement (DOCX) - (MS05G)
- Individual Medicare Supplement (DOCX) - (MS05I)
- Group Vision Plans (DOCX) - (H20G)
- Individual Vision Plans (DOCX) - (H20I)
- Prescription Drug Coverage Only (DOCX) – (H17G and H17I)
- Out-of-State Groups, Associations/Trusts/ Labor Union Group/Debtor Groups/Other Groups (DOCX) - (H21 Other)
- Association Questionnaire (DOC)
- Legal Services Coverage (DOCX) (H21-Other)
- MEWAs (DOCX) - (H21 Other)
- Multi-Line Applications (DOCX)
- Health Application (DOCX)
- Part-D-Supplemental (DOCX)
Rate Filing Requirements
- Credit (DOCX)- (CR02G & CR04G )
- Individual Health Policies, other than Medicare Supplement, Long Term Care, and Individual Health Plans (DOCX) - (H01, H02I, H03I, H07I, H08I, H09I, H10I, H11I, H13I, H14I, H16I.004, H17I, H19I, H20I)
- Group Health including Qualified SADP (DOCX) Policies Subject to Title 24-A M.R.S.A. § 2839 H02G, H03G, H04, H07G, H08G, H09G, H10G, H11G, H12, H13G, H14G, H15G.002, H16G.002A, H16G.002B, H16G.002C, H16G.004, H17G, H18G, H19G, H20G, HOrg02G.003B
- Long Term Care/Nursing Home Care (DOCX) - (LTC03G, LTC03I) - subject to Rule 420 (policies issued prior to 10/1/04)
- Long Term Care (DOCX) - (LTC03G, LTC03I) - Initial Rate Filing for policies subject to Rule 425 (policies issued on and after 10/1/04)
- Long Term Care (DOCX) - (LTC03G, LTC03I) - Rate Revision Filing for policies subject to Rule 425 (policies issued on and after 10/1/04)
- Medicare Supplement (DOCX) - (MS02G, MS02I, MS05G, MS05I)
Life, Annuity & Credit Form Filing Requirements
- Annuities (DOCX)
- Variable Annuities (DOCX)
- Group Life (DOCX)
- Individual Life (DOCX)
- Variable Life (DOCX)
- Life Settlements and Viatical Settlements (DOCX) (LS01 and VS01)
- Illustrations (DOCX) - (L08)
- Group Credit Life and/or Disability (DOCX) - (CR04G and/or CR02G)
- Individual Credit Life and/or Disability (DOCX) - (CR04I and/or CR02I)
- Life, Annuity & Credit APPLICATIONS (DOCX) (Group & Individual)