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Document Sample
NJ Department of Banking & Insurance
Division of Insurance, Office of Property & Casualty
Homeowners Annual Price Comparison Survey
N.J.A.C. 11:4-29
20041209
Evaluated as of December 31, 2009
NAIC Group # 0000 Group Name GroupName
NAIC Company # 00000 Company Name CompanyName
Contact Person's Name: enter name here Corporate Officer's Name: enter name here
Contact Person's Title: enter title here Corporate Officer's Title: enter title here
Contact Person's Telephone: enter phone number here Corporate Officer's Telephone: enter phone number here
Contact Person's E-Mail: enter e-mail address here Corporate Officer's E-Mail: enter e-mail address here
Signature of Officer or Senior Manager
Instructions:
* Submit one spreadsheet per company per tier (even if rates are identical).
* E-Mail spreadsheet or any questions to reports@dobi.state.nj.us. This form with signature must be mailed in or faxed to 609-777-0019.
* Type over (not next to) the blue text above and on appendicies. Do not add or delete any rows, columns, or sheets. Do not change any headings.
* Premium is annual for all examples. Counties are other than any listed cities.
* For examples that don't apply, enter the premium as N/A and the exposures as 0.
Comments:
6/29/2010 7:55 PM
Homeowners Annual Price Comparison Survey - Example A - 2009
0000 GroupName - 00000 CompanyName
Premium
Specified Criteria in Regulation Actual Criteria Used City/County Tier 1 Tier 2 Tier 3
Policy Form HO-3 type here 1 Bayonne (Hudson) $0.00 $0.00 $0.00
Frame Structure type here 2 Camden (Camden) $0.00 $0.00 $0.00
Built 5 Years Ago as of Evaluation Date type here 3 Clifton (Passaic) $0.00 $0.00 $0.00
Smoke Detector Present type here 4 East Orange (Essex) $0.00 $0.00 $0.00
Dwelling Amount $225,000 type here 5 Elizabeth (Union) $0.00 $0.00 $0.00
Personal Liability $300,000 type here 6 Jersey City (Hudson) $0.00 $0.00 $0.00
Medical Payments $1,000 type here 7 Newark (Essex) $0.00 $0.00 $0.00
Deductible $500 type here 8 Passaic (Passaic) $0.00 $0.00 $0.00
Within 5 miles of fire station type here 9 Paterson (Passaic) $0.00 $0.00 $0.00
Within 1000' of hydrant or usable suction point type here 10 Trenton (Mercer) $0.00 $0.00 $0.00
Dwelling Amount on replacement cost basis type here 11 Woodbridge (Middlesex) $0.00 $0.00 $0.00
Contents Amount on replacement cost basis type here 12 Atlantic County $0.00 $0.00 $0.00
Surcharges Included type here 13 Bergen County $0.00 $0.00 $0.00
14 Burlington County $0.00 $0.00 $0.00
If Your Policy Differs From Above, Please Explain: 15 Camden County $0.00 $0.00 $0.00
16 Cape May County $0.00 $0.00 $0.00
17 Cumberland County $0.00 $0.00 $0.00
18 Essex County $0.00 $0.00 $0.00
19 Gloucester County $0.00 $0.00 $0.00
List Any Dividends Your Company Offers: 20 Hudson County $0.00 $0.00 $0.00
21 Hunterdon County $0.00 $0.00 $0.00
22 Mercer County $0.00 $0.00 $0.00
23 Middlesex County $0.00 $0.00 $0.00
Identify any special eligibility criteria company may have: 24 Monmouth County $0.00 $0.00 $0.00
25 Morris County $0.00 $0.00 $0.00
26 Ocean County $0.00 $0.00 $0.00
27 Passaic County $0.00 $0.00 $0.00
28 Salem County $0.00 $0.00 $0.00
29 Somerset County $0.00 $0.00 $0.00
In-Force Polices as of: 30 Sussex County $0.00 $0.00 $0.00
January 1, 2009 0 31 Union County $0.00 $0.00 $0.00
December 31, 2009 0 32 Warren County $0.00 $0.00 $0.00
6/29/2010 7:55 PM
Homeowners Annual Price Comparison Survey - Example B - 2009
0000 GroupName - 00000 CompanyName
Premium
Specified Criteria in Regulation Actual Criteria Used City/County Tier 1 Tier 2 Tier 3
Policy Form HO-4 type here Bayonne (Hudson) $0.00 $0.00 $0.00
Contents Amount $20,000 type here Camden (Camden) $0.00 $0.00 $0.00
Personal Liability $300,000 type here Clifton (Passaic) $0.00 $0.00 $0.00
Medical Payments $1,000 type here East Orange (Essex) $0.00 $0.00 $0.00
Smoke Detector type here Elizabeth (Union) $0.00 $0.00 $0.00
Deductible $500 type here Jersey City (Hudson) $0.00 $0.00 $0.00
Within 5 miles of fire station type here Newark (Essex) $0.00 $0.00 $0.00
Within 1000' of hydrant or usable suction point type here Passaic (Passaic) $0.00 $0.00 $0.00
Contents Amount on replacement cost basis type here Paterson (Passaic) $0.00 $0.00 $0.00
Surcharges Included type here Trenton (Mercer) $0.00 $0.00 $0.00
Woodbridge (Middlesex) $0.00 $0.00 $0.00
Atlantic County $0.00 $0.00 $0.00
Bergen County $0.00 $0.00 $0.00
Burlington County $0.00 $0.00 $0.00
If Your Policy Differs From Above, Please Explain: Camden County $0.00 $0.00 $0.00
Cape May County $0.00 $0.00 $0.00
Cumberland County $0.00 $0.00 $0.00
Essex County $0.00 $0.00 $0.00
Gloucester County $0.00 $0.00 $0.00
List Any Dividends Your Company Offers: Hudson County $0.00 $0.00 $0.00
Hunterdon County $0.00 $0.00 $0.00
Mercer County $0.00 $0.00 $0.00
Middlesex County $0.00 $0.00 $0.00
Identify any special eligibility criteria company may have: Monmouth County $0.00 $0.00 $0.00
Morris County $0.00 $0.00 $0.00
Ocean County $0.00 $0.00 $0.00
Passaic County $0.00 $0.00 $0.00
Salem County $0.00 $0.00 $0.00
Somerset County $0.00 $0.00 $0.00
In-Force Polices as of: Sussex County $0.00 $0.00 $0.00
January 1, 2009 0 Union County $0.00 $0.00 $0.00
December 31, 2009 0 Warren County $0.00 $0.00 $0.00
6/29/2010 7:55 PM
Homeowners Annual Price Comparison Survey - Example C - 2009
0000 GroupName - 00000 CompanyName
Premium
Specified Criteria in Regulation Actual Criteria Used City/County Tier 1 Tier 2 Tier 3
Policy Form HO-6 type here Bayonne (Hudson) $0.00 $0.00 $0.00
Owner Occupied Only type here Camden (Camden) $0.00 $0.00 $0.00
Contents Amount $40,000 type here Clifton (Passaic) $0.00 $0.00 $0.00
Personal Liability $300,000 type here East Orange (Essex) $0.00 $0.00 $0.00
Medical Payments $1,000 type here Elizabeth (Union) $0.00 $0.00 $0.00
Smoke Detector type here Jersey City (Hudson) $0.00 $0.00 $0.00
Deductible $500 type here Newark (Essex) $0.00 $0.00 $0.00
Within 5 miles of fire station type here Passaic (Passaic) $0.00 $0.00 $0.00
Within 1000' of hydrant or usable suction point type here Paterson (Passaic) $0.00 $0.00 $0.00
Contents Amount on replacement cost basis type here Trenton (Mercer) $0.00 $0.00 $0.00
Woodbridge (Middlesex) $0.00 $0.00 $0.00
Atlantic County $0.00 $0.00 $0.00
Bergen County $0.00 $0.00 $0.00
Burlington County $0.00 $0.00 $0.00
If Your Policy Differs From Above, Please Explain: Camden County $0.00 $0.00 $0.00
Cape May County $0.00 $0.00 $0.00
Cumberland County $0.00 $0.00 $0.00
Essex County $0.00 $0.00 $0.00
Gloucester County $0.00 $0.00 $0.00
List Any Dividends Your Company Offers: Hudson County $0.00 $0.00 $0.00
Hunterdon County $0.00 $0.00 $0.00
Mercer County $0.00 $0.00 $0.00
Middlesex County $0.00 $0.00 $0.00
Identify any special eligibility criteria company may have: Monmouth County $0.00 $0.00 $0.00
Morris County $0.00 $0.00 $0.00
Ocean County $0.00 $0.00 $0.00
Passaic County $0.00 $0.00 $0.00
Salem County $0.00 $0.00 $0.00
Somerset County $0.00 $0.00 $0.00
In-Force Polices as of: Sussex County $0.00 $0.00 $0.00
January 1, 2009 0 Union County $0.00 $0.00 $0.00
December 31, 2009 0 Warren County $0.00 $0.00 $0.00
6/29/2010 7:55 PM
Homeowners Annual Price Comparison Survey - HO-3 Replacement Cost - 2009
0000 GroupName - 00000 CompanyName
1. Is guaranteed replacement cost available? choose
2. Choose an answer above. choose
3. Choose an answer above. choose
4. Choose an answer above. choose
5. Choose an answer above. enter here
6/29/2010 7:55 PM
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