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| Home > Insurance Division > Health Insurance Programs > IHC > Forms |
| IHC Program Forms |
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| Standard Plans, Riders and Enrollment Forms (For Plans Issued on or After January 1, 2025) |
| Plans A/50, B, C, and D (Exhibit A) |
MS Word |
| HMO Plan (Exhibit B) |
MS Word |
| Explanation of Brackets Plans A/50 through D and HMO (Exhibit C) |
MS Word |
| Compliance and Variability Rider (Exhibit D) |
MS Word |
| Non-Group Enrollment Form |
MS Word |
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| Standard Plans, Riders and Enrollment Forms (For Plans Issued on or After January 1, 2024) |
| Plans A/50, B, C, and D (Exhibit A) |
MS Word |
| HMO Plan (Exhibit B) |
MS Word |
| Explanation of Brackets Plans A/50 through D and HMO (Exhibit C) |
MS Word |
| Compliance and Variability Rider (Exhibit D) |
MS Word |
| Non-Group Enrollment Form |
MS Word |
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| Standard Plans, Riders and Enrollment Forms (For Plans Issued on or After January 1, 2023) |
| Plans A/50, B, C, and D (Exhibit A) |
MS Word |
| HMO Plan (Exhibit B) |
MS Word |
| Explanation of Brackets Plans A/50 through D and HMO (Exhibit C) |
MS Word |
| Compliance and Variability Rider (Exhibit D) |
MS Word |
| Non-Group Enrollment Form |
MS Word |
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| Standard Plans, Riders and Enrollment Forms (For Plans Issued on or After January 1, 2022) |
| Plans A/50, B, C, and D (Exhibit A) |
MS Word |
| HMO Plan (Exhibit B) |
MS Word |
| Explanation of Brackets Plans A/50 through D and HMO (Exhibit C) |
MS Word |
| Compliance and Variability Rider (Exhibit D) |
MS Word |
| Non-Group Enrollment Form |
MS Word |
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| Standard Plans, Riders and Enrollment Forms (For Plans Issued on or After January 1, 2019) |
| Plans A/50, B, C, and D (Exhibit A) |
MS Word |
| HMO Plan (Exhibit B) |
MS Word |
| Explanation of Brackets Plans A/50 through D and HMO (Exhibit C) |
MS Word |
| Compliance and Variability Rider (Exhibit D) |
MS Word |
| Non-Group Enrollment Form |
MS Word |
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| Standard Plans, Riders and Enrollment Forms (For Plans Issued on or After January 1, 2018) |
| Plans A/50, B, C, and D (Exhibit A) |
MS Word |
| HMO Plan (Exhibit B) |
MS Word |
| Explanation of Brackets Plans A/50 through D and HMO (Exhibit C) |
MS Word |
| Compliance and Variability Rider (Exhibit D) |
MS Word |
| Non-Group Enrollment Form |
MS Word |
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| Standard Plans, Riders and Enrollment Forms (For Plans Issued on or After May 16, 2017) |
| Plans A/50, B, C, and D (Exhibit A) |
MS Word |
| HMO Plan (Exhibit B) |
MS Word |
| Explanation of Brackets Plans A/50 through D and HMO (Exhibit C) |
MS Word |
| Compliance and Variability Rider (Exhibit D) |
MS Word |
| Non-Group Enrollment Form |
MS Word |
| Non-Group Conversion Form |
MS Word |
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| Standard Plans, Riders and Enrollment Forms (For Plans Issued on or After January 1, 2017) |
| Plans A/50, B, C, and D (Exhibit A) |
MS Word |
| HMO Plan (Exhibit B) |
MS Word |
| Explanation of Brackets Plans A/50 through D and HMO (Exhibit C) |
MS Word |
| Compliance and Variability Rider (Exhibit D) |
MS Word |
| Non-Group Enrollment Form |
MS Word |
| Non-Group Conversion Form |
MS Word |
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| Standard Plans, Riders and Enrollment Forms (For Plans Issued on or After January 1, 2016) |
| Plans A/50, B, C, and D (Exhibit A) |
MS Word |
| HMO Plan (Exhibit B) |
MS Word |
| Explanation of Brackets Plans A/50 through D and HMO (Exhibit C) |
MS Word |
| Compliance and Variability Rider (Exhibit D) |
MS Word |
| Non-Group Enrollment Form |
MS Word |
| Non-Group Conversion Form |
MS Word |
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| Reporting Forms |
| Certification of Compliance with Individual Health Coverage Plans |
Exhibit E (formerly Exhibit Q) (MS Word) UPDATED
Worksheet (MS Excel) |
| Identification of Plans |
Exhibit H (MS Word) |
| Loss Ratio report |
Exhibit J (PDF, rev. 2009) |
| Assessment Report |
Exhibit K (MS Word) |
| Enrollment Report - Quarterly |
Exhibit L – Part 1 (MS Excel) |
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| Filing Deadlines |
| * |
NLT** |
Exhibit |
Report Description |
N.J.A.C. Reference |
| A |
Feb. 28 |
Exhibit L - Part 1
(MS Excel) |
Quarterly Enrollment Report |
11:20-17.3 |
| A |
Mar 1† |
Exhibit E (MS Word)
Worksheet (MS Excel) |
Certification of Compliance |
11:20-3.2 |
| B |
Apr 1 |
Notice of Annual Filing Requirements (Instructions)
Exhibit K
(MS Word)
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Assessment report (premium data, enrollment data, adjusted net earned premium) |
11:20-8.2 through 8.4 |
| A |
May 31 |
Exhibit L – Part 1
(MS Excel) |
Quarterly Enrollment Report |
11:20-17.3 |
| A |
Aug 31 |
Exhibit L – Part 1
(MS Excel) |
Quarterly Enrollment Report |
11:20-17.3 |
| A |
Aug 15 |
Exhibit J
(PDF, rev. 2009)) |
Loss Ratio Report (and refund plan, if required) |
11:20-7.4 |
| A |
Nov 30 |
Exhibit L – Part 1
(MS Excel) |
Quarterly Enrollment Report |
11:20-17.3 |
| †† |
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*** |
Informational rate filings |
11:20-6.3 |
| Rules regarding the IHC Program are set forth in the New Jersey Administrative Code (N.J.A.C.) at 11:20, available through LexisNexis® free online at www.lexisnexis.com/hottopics/njcode/ |
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| *This column indicates the frequency for filing the report. A= annually. B= biannually, in odd-numbered years. |
| **NLT= no later than the date specified, unless the Board issues a bulletin extending a deadline. The Board issues bulletins to carriers on the Board’s mailing list and posts bulletins to the Board’s website. |
| ***There is no form; the rules specify the information that must be submitted. |
| †Exhibit E also must be filed before marketing, issuing or renewing any standard policy form. |
| ††These reports must be filed prior to using the rates; rates cannot be stated for a period exceeding 12 months. For more information, see the Common Rate Filing Questions under the Rate Filing Resources for Carriers section at www.state.nj.us/dobi/lifehealthactuarial/rateinfo/. |
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