WSHIP assessment report

This report is due each year on March 1.

Required fields are marked with an *.

1. Company Information
*Is this a revised report? If so, explain in comments after declaration. Yes   No
  No revisions will be accepted after June 30th.
*NAIC#:   Choose from the list
*Company:
*Contact:
(first name   last name)
*Email:
(Receives email copy of this form.)
*Contact address:
*City:*State: *Zip:
*Phone:
  Ext: Fax:
2. Enrollment Affidavits

*Do you have Washington resident insured persons to list in sections 2a. Health plans or
2b. Stop-Loss Coverage for Self-Insured? Yes   No

If no, please skip to section 4. Questions.
2a. Health plans
Do you have Washington resident enrollees in any health plans below?
  • If no, go to 2b, Stop-Loss Coverage for Self-Insured.
  • If yes, enter the number of enrollees for the specific health plan. Do not include any enrollees from the Exclusion List. Click here for exclusion list
 Group
Health
Plans		 Individual Health
Plans		Basic
Health, includes
BH Plus		 Apple Health (Medicaid), includes
SCHIP		 Medicare Supplement PlansTotal
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Total

2b. Stop-Loss Coverage for Self-Insured
Do you have Washington resident enrollees with coverage through a self-insured plan that has been reinsured by your stop-loss plan?
  • If no, continue to 3, Contact information.
  • If yes, fill out this section.
Enter the number of enrollees for the specific month.
JanFebMarAprMayJun
JulAugSepOctNovDecTotal

3. Contact Information
Only fill out 3a and 3b if you entered Washington resident enrollee numbers in either the 2a Health Plans or the 2b Stop-loss coverage sections.
3a. Billing Information
Name:
(first name   last name)		Phone:
Ext:
Address:
City:State:
Zip:
Email:

3b. WSHIP Board Voting Representative

Insurers that are WSHIP members elect four members of the WSHIP Board. See RCW 48.41.040(2).  Each company’s vote is weighed by the number of persons it has in health plans subject to WSHIP assessments.  For more information about WSHIP Board voting see the WSHIP web site page “ About WSHIP -  Plan of Operations”.

This is the person who votes for their WSHIP board representative.

Name:
(first name   last name)		 Phone:
Ext:
Title:
Email:
Address:
City: State:
Zip:

4. Questions
If you've had major changes in enrollment numbers since last year, please explain.


If your company has been involved with a merger or name change, please explain how this affects your reporting.


If you're reporting for a company(ies) you acquired during the year, provide the company name and NAIC#.

5. Declaration
I hereby declare under penalty of perjury under the laws of the State of Washington that the enrollment information provided on this report is true and correct. I am authorized to execute this declaration on behalf of (name of company) * and certify that this named company understands that this information will be used to calculate the assessment due and owing to the Washington State Health Insurance Pool.
*Executed:
(date - mmddyyyy)		 *At:
(city & state)
*By:
(officer)