Checklists Life - Accident - Health

Please use the up-to-date checklists provided on this page. Filings submitted with out-of-date checklists will be rejected.

• Health Premium Rates Checklist 

• Rate Review Checklist — Individual 

• Rate Review Checklist — Small Group 

• Actuarial Certification — PDF | Word Document

• Actuarial Memorandum 

• Non-ACA Health Premium Rates 

• Rate Data Collection Form - Excel

• Student Blanket Rate Review Checklist - Excel 

NEW FOR ALL FILINGS OFFERING MENTAL HEALTH BENEFITS: The Mental Health Parity Supporting Document template must be attached under the supporting documentation tab of all form filings offering mental health benefits. Filings without this documentation will not be reviewed.

• Checklist for Carrier External Review Notices
  
• Blanket Accident 
• Fraternal Review Requirements 
• Illinois Network Adequacy (Tiered) Collection Template -  Excel
• Individual Excepted Benefit Checklist
  
• Large Group HMO-POS Checklist
• Large Group PPO Checklist 
• Large Group Accident Health Stand Alone Dental 
• Long Term Care Traditional & Partnership Program Checklist Rev. 12-05-23
• Network Adequacy County Facilities - Excel
  
• Network Adequacy Exception Form
  
• Network Adequacy & Transparency Checklist 
• Proposed Enrollment Template
• Medicare Supplement Checklist 
• Mental Health Parity Supporting Documentation Checklist 
• Short Term Limited Duration Checklist 
• ACA Student Health Checklist

Excess Risk/Stop Loss filings are done on an INFORMATIONAL basis

Note: Documents must be saved as PDFs before uploading to SERFF.

• Accelerated Benefits for Terminal Illness/Covered Condition 
• Accidental Death Benefits Individual and Group Products Rev. 01-24-22
• Additional Benefits — Individual & Group Total Permanent Disability
• Annuity Filing checklist Rev. 3-3-22
• Individual Equity Indexed Annuity Rev. 01-24-22
• Fraternal Benefit Society Guidelines Rev. 11-03-21
• Group Annuity Rev. 3-3-22
• Group Term Life Rev. 03-08-22
• Group Universal Life Rev. 03-19-24
• Group Whole Life Rev. 05-05-22
• Individual Annuity Fixed Premium Rev. 01-24-22
• Individual Annuity Flexible Premium Rev. 03-08-22
• Individual Immediate Annuity Rev. 11-03-21
• Individual Term Life Rev. 11-03-21
• Individual Universal Life Rev. 11-30-21
• Individual Variable Annuity Rev. 03-08-22
• Individual Variable Life Rev. 11-03-21
• Individual Variable Universal Life (Flexible and Fixed Premium) Rev. 01-24-22
• Individual Whole Life Insurance Rev. 11-29-21 
• General Account Modified Guaranteed Annuity Rev. 11-03-21
• Supplemental Individual Life Filing Checklist - New 12/10/20

• Credit Accident Health & Life Checklist

• Assumption Certificate Guidelines Rev. 09-20-23
• Combination Life and Accident & Health Coverages Filing Guidelines – Rev. 10/27/21 
  
• Merger Endorsement Guidelines Rev. 09-20-23
  
• Name Change Endorsement Guidelines Rev. 09-20-23

• Viatical Settlements Broker Requirements Rev. 11-29-21

• Viatical Settlements Contracts Rev. 3-3-22

Reporting Template

• General NQTL Reporting Form

Reporting Instructions for:

• Concurrent Review
• Experimental Investigational
• Failure to Complete
• Formulary Tiering
• Medical Necessity Criteria
• Outlier Review
• Prior Authorization
• Reimbursement
• Retrospective Review
• Step Therapy