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 Life and Health checklists, please contact Lisa Lewis, Senior Insurance Analyst, at Lisa.A.Lewis@maine.gov or call 207-624-8417.

image of adobe acrobat reader icon NOTE: You must have the free Adobe Acrobat Reader to open PDF files. Get it here.

The documents on this page are also available in hard copy by contacting the Bureau.

Non-QHP Requirements Checklists

Accident & Health Form Filing Requirements
Word Group Accident Only - (H02G) REVISED 11/21/2019
Word Individual Accident Only - (H02I) REVISED 11/21/2019
Word Group Accidental Death & Dismemberment - (H03G) REVISED 11/21/2019
Word Individual Accidental Death & Dismemberment - (H03I) REVISED 11/21/2019
Word Blanket Accident and Sickness - (H04) REVISED 11/21/2019
Word Blanket Accident Only - (H04) REVISED 11/21/2019
Word / PDF Student Health Insurance - ACA Compliant- (H22) REVISED 10/11/2019
Word / PDF Group Specified Disease - (H07G) REVISED 11/21/2019
Word / PDF Individual Specified Disease - (H07I) REVISED 11/21/2019
Word / PDF Group Dental NON-Qualified - (H10G) REVISED 10/11/2019
Word / PDF Individual Dental NON-Qualified - (H10I) REVISED 10/11/2019
Word Group Disability Income - (H11G) REVISED 11/21/2019
Word Individual Disability Income - (H11I) REVISED 11/21/2019
Word Group Disability - Maine Tax Credit Qualified STD and LTD - (H11G.004 Other) REVISED 11/21/2019
Word Excess/Stop Loss - (H12) REVISED 9/17/2019
Word Group Short Term Care (H13G) REVISED 10/1/2018
Word / PDF Group Hospital Confinement Indemnity - (H14G) REVISED 1/28/2020
Word / PDF Individual Hospital Confinement Indemnity - (H14I) REVISED 1/28/2020
Word / PDF Group Indemnity Other Than Hospital - (H23G) REVISED 1/28/2020
Word / PDF Individual Indemnity Other Than Hospital - (H23I) REVISED 1/28/2020
Word Group Hospital/Surgical/Medical Expense - (H15G) AMENDED 09/2012
Word / PDF
Word / PDF
Large Group Major Medical - (H16G) *2020* REVISED 04/8/2020
Large Group Major Medical - (H16G) *2021* REVISED 04/8/2020
Word
Word
Individual Major Medical SHORT-TERM, LIMITED-DURATION - (H16I.004) REVISED 10/10/2019
Short-term, Limited-duration Policy - Summary of Plan Benefits
Word / PDF
Word / PDF
Large Group HMO-POS - (HOrg02G) *2020* REVISED 04/8/2020
Large Group HMO-POS - (HOrg02G) *2021* REVISED 04/8/2020
Word Group & Individual Long Term Care/Partnership - (LTC03G and LTC03I) REVISED 11/21/2019
Word Group Medicare Supplement - (MS05G) REVISED 10/2/2018
Word Individual Medicare Supplement - (MS05I) REVISED 10/2/2018
Word Group Vision Plans - (H20G) REVISED 10/2/2018
Word Individual Vision Plans - (H20I) AMENDED 10/2/2018
Word Individual Basic Hospital Expense - (H21 Other)
Word Individual Basic Hospital/Medical-Surgical Expense - (H21 Other)
Word Individual Basic Medical Expense - (H21 Other)
Word Individual Basic Medical-Surgical Expense - (H21 Other)
Word / PDF Group Basic Hospital Expense - (H21 Other)
Word / PDF Group Basic Hospital/Medical/Surgical Expense - (H21 Other)
Word / PDF Group Basic Medical Expense - (H21 Other)
Word / PDF Group Basic Medical/Surgical Expense - (H21 Other)
Word / PDF Group Similar Supplemental to Major Medical (H25G) REVISED 3/20/2020
Word Out-of-State Groups, Associations/Trusts/
Labor Union Group/Debtor Groups/Other Groups - (H21 Other) REVISED 1/11/2019
Word / PDF Association Questionnaire
Word / PDF Legal Services Coverage (H21-Other) NEW 05/11/2020
Word MEWAs - (H21 Other)
Word Multi-Line Applications REVISED 4/4/2019
Word Health Application REVISED 4/4/2019
Rate Filing Requirements
Word Credit - (CR02G & CR04G )
Word Individual Health Policies, other than Medicare Supplement, Long Term Care, and Individual Health Plans - (H01, H02I, H03I, H07I, H08I, H09I, H10I, H11I, H13I, H14I, H16I.004, H17I, H19I, H20I)
Word Group Health including Qualified SADP 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
Word Individual Health Plans - (H15I, H16I.005A, H16I.005B, H16I.005C, HOrg02I.005B, HOrg02I.005C) REVISED 3/10/2020
Word Long Term Care/Nursing Home Care - (LTC03G, LTC03I) - subject to Rule 420 (policies issued prior to 10-01-04)
Word Long Term Care - (LTC03G, LTC03I) - Initial Rate Filing for policies subject to Rule 425 (policies issued on and after 10-01-04)
Word Long Term Care - (LTC03G, LTC03I) - Rate Revision Filing for policies subject to Rule 425 (policies issued on and after 10-01-04)
Word Medicare Supplement - (MS02G, MS02I, MS05G, MS05I)
Life, Annuity & Credit Form Filing Requirements
Word Annuities - REVISED 11/21/2019
Word Variable Annuities - REVISED 11/21/2019
Word Group Life - REVISED 11/21/2019
Word Individual Life - REVISED 11/21/2019
Word Variable Life - REVISED 11/21/2019
Word Life Settlements and Viatical Settlements (LS01 and VS01)  NEW 4/5/2018
Word Illustrations - (L08)
Word Group Credit Life and/or Disability - (CR04G and/or CR02G) REVISED 11/21/2019
Word Individual Credit Life and/or Disability - (CR04I and/or CR02I) REVISED 11/21/2019
Word Life, Annuity & Credit APPLICATIONS (Group & Individual)