Checklists for Life and Health Insurance Products
The Checklists are intended to expedite the Life & Health Division’s overall review time of new form filings. The Checklists serve as basic guides to assist the industry in preparation of new form filings prior to submission. The checklists are not a substitute for Departmental review. All forms must comply with state insurance law.
Checklists are available for many types of insurance. If a specific type of insurance is not included, contact the Life & Health Division at the email below for further guidance.
Completing a checklist
The right-hand column of each checklist is intended to be used to provide a reference (such as a page or paragraph number) from within the insurance form where the specific regulatory item is located. If an item is not applicable to the submission, place an N/A in the cell and provide an explanation why the item is not applicable. Some items listed in the checklist are for informational purposes only. Place a check in the box next to the item (if applicable) to indicate compliance with the requirement.
The Checklists are in Excel format and have been password protected to prevent changes to them except within the specified cells. If you have any questions about the checklist, contact the Life & Health Division at LHinbox@ncdoi.gov.
Clicking on a checklist will open it as an Excel file.
Health Insurance Form and Rate Filing Checklists
Association Group Questionnaire
- Accidental Death and Dismemberment Form and Rate Filing Checklist
- Accident Form and Rate Filing Checklist
- Blanket Accident Form and Rate Filing Checklist
- Blanket Accident and Health Form and Rate Filing Checklist
- Cancer Form and Rate Filing Checklist
- Conversion Form and Rate Filing Checklist
- Dental Form and Rate Filing Checklist
- Disability Form and Rate Filing Checklist
- Franchise Form and Rate
Filng Checklist - Major Medical/PPO - Group Form and Rate Filing Checklist
- Rates - Group - Filing Checklist
- Health Maintenance Organization - Form and Rate Filing Checklist
- Rates - HMO - Filing Checklist
- Home Health Care Form and Rate Filing Checklist
- Hospital Surgical Fixed Indemnity Form and Rate Filing Checklist
- Rates - Individual - Filing Checklist
- Major Medical/PPO - Individual Form and Rate Filing Checklist
- Mental Health Parity Checklist
- Long Term Care Form and Rate Filing Checklist
- Medicare Supplement Form and Rate Filing Checklist
- PPO Operations Filing Form/ Checklists / Attestation
- Provider/Intermediary Contract Compliance Checklist
Short Term Limited Duration Health Form and Rate Filing Checklist- Small Group Tax Credit Certification Checklist
- Stop Loss Form and Rate Filing Checklist
- Vision Form and Rate Filing Checklist
External Review Model Evidence of Coverage Language and Written Notice
North Carolina law provides for a review of a health plan's decision to deny coverage for payment of a service (non-certification decision). N.C.G.S. § 58-50-75 gives covered persons the opportunity for an independent review of a non-certification decision by an external, Independent Review Organization (IRO). An external review either upholds the health plan's decision or overturns all or some of the decision. The health plan must accept the binding decision.
N.C.G.S. § 58-50-77 requires the insurer to provide a written notice to the covered person explaining the right to request an external review. This written notice must contain specific information. N.C.G.S. § 58-50-93 also requires insurers to describe the external review procedures in or attached to the evidence of coverage. To assist insurers in complying with the general statutes the North Carolina Department has developed suggested model contract language and notice language.
Model Evidence of Coverage (EOC) Language
Credit Insurance Form and Rate Filing Checklists
Life and Annuity Form and Rate Filing Checklists
Association Group Questionnaire
- Group Fixed Annuity Form and Rate Filing Checklist
- Group Term Life Form and Rate Filing Checklist
- Group Variable Annuity Form and Rate Filing Checklist
- Group Variable Life Form and Rate Filing Checklist
- Group Whole/Universal Life Form and Rate Filing Checklist
- Individual Fixed Annuity Form and Rate Filing Checklist
- Individual Term Life Form and Rate Filing Checklist
- Individual Variable Annuity Form and Rate Filing Checklist
- Individual Variable Life Form and Rate Filing Checklist
- Individual Whole/Universal Life Form and Rate Filing Checklist
- Life and Annuity Applications Form Filing Checklist
Life Riders and Amendments Form and Rate Filing Checklist- Replacement Notices - Appendices A, B and C
Assumption Reinsurance Transactions Forms and Rate Filings Checklist and Information
LTC Partnership Compliance Certification Form
Stop Loss - Small Employer Groups - 19 or Less Eligible Employees
Stop Loss Insurance Requirements - Employers with 19 or Less Eligible Employees
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