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Wyoming Small Employer Health - Wyoming Insurance Department.doc

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					                   WYOMING SMALL EMPLOYER HEALTH INSURANCE

                                        Annual Report


TO: SMALL EMPLOYER HEALTH INSURANCE COMPLIANCE DIVISION

FROM: (Please type or print)

NAME OF COMPANY:

NAIC NUMBER:

NAME OF CONTACT PERSON:

TITLE:

TELEPHONE NUMBER:

DATE:

ADDRESS:



*1.            A.      Number of small employers in Wyoming that were issued health
               benefit plans during the preceding calendar year:

        B.     Number of small employers in Wyoming that had health benefit plans
               renewed during the preceding calendar year:

        C.     Number of small employers in Wyoming issued health benefit plans who
               were previously insured with another carrier:

*2.    Number of small employer plans issued and renewed in Wyoming during
preceding year (provide the following for each class of business):

        Class of Business    Number Issued         Number Renewed        Total Number


3.      The number of small employer health benefit plans in force in each county (or by
        zip code) of Wyoming as of December 31 of the preceding year:

4.      The number of small employer health benefit plans in Wyoming that were
        voluntarily not renewed by small employers in the previous calendar year:
5.     The number of small employer health benefit plans in Wyoming that were
       terminated or nonrenewed (for reasons other than nonpayment of premium) by
       [Name of small employer carrier] in the previous calendar year:

6.     The number of small employer health benefit plans that were issued during the
       previous calendar year to small employers in Wyoming that were uninsured for at
       least three (3) months prior to issue:

*7.    The total amount of direct premium for small employer health benefit plans in
       Wyoming for the preceding calendar year:

*8.    The total amount of first year direct premium for new small employer health
       benefit plans in Wyoming for the preceding calendar year:

9.     Did you actively market small employer health benefit plans in Wyoming during
       the preceding calendar year?


Signature

Name (typed or printed)

Title (typed or printed)




* See supplemental data sheet for detail by group size.

				
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