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Bulletin 332

Health Insurance Annual Report Supplement – Amended “Short” Form

Rule 945 was adopted on February 13, 2005, and requires health insurers to file an annual report supplement for specified types of health insurance. Those with less than $2,000,000 of direct written premium Maine need only file the “short” form described in Appendix B of the Rule. It has come to our attention that the form in Appendix B is missing a line for the increase in reserves and therefore the formula for underwriting gain is inaccurate. The “short” form in Appendix B is hereby replaced with the attached form. The corrected form is also posted on the Bureau’s web site at

The increase in reserves should be reported on a basis consistent with line 22 of the Statement of Revenue and Expenses on the Health annual statement blank or with line 6 of Schedule H Part 1 on the Life or Property/Casualty blank.

Insurers that have already filed the short form are asked to refile using the corrected form. We apologize for the inconvenience.

Questions concerning this bulletin can be addressed to Rick Bergeron at or 207-624-8439.

April 5, 2005 _______________________________
Alessandro A. Iuppa
Superintendent of Insurance

NOTE: This bulletin is intended solely for informational purposes. It is not intended to set forth legal rights, duties or privileges nor is it intended to provide legal advice. Readers are encouraged to consult applicable statutes and regulations and to contact the Bureau of Insurance if additional information is needed.


This form is for companies with less than $2 million of premium – see Rule 945, section 5.

Statewide Data

Company ______________________________________________________ NAIC Code _____

Name of person completing this form _______________________________

Telephone Number ____________ Email ____________________________________
Large Groups Small Groups Individ-
uals Dirigo Groups Dirigo Individ-
uals Stop-
loss TOTAL
1 Net premium income
2 Total revenues
3 Total medical and hospital expenses
4 Total claims adjustment and administrative expenses
5 Increase in reserves
6 Net underwriting gain or (loss) (line 2 less line 3 less line 4 less line 5)

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Last Updated: September 27, 2010