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Fill and Sign the Colorado Workers Compensation Claim Handling Guidelines Form

Fill and Sign the Colorado Workers Compensation Claim Handling Guidelines Form

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SERFF Tracking Number: BNLC-125613682 State: Arkansas Filing Company: Colonial Penn Life Insurance Company State Tracking Number: 38936 TOI: L07I Individual Life - Whole Sub-TOI: L07I.121 Graded Premium - Single Life Product Name: Whole Life Application Project Name/Number: / Company Tracking Number: Filing at a Glance Company: Colonial Penn Life Insurance Company Product Name: Whole Life Application SERFF Tr Num: BNLC-125613682 TOI: L07I Individual Life - Whole SERFF Status: Closed Sub-TOI: L07I.121 Graded Premium - Single Co Tr Num: Life Filing Type: Form Co Status: Author: Karen Schussler Date Submitted: 05/09/2008 Implementation Date Requested: On Approval State: ArkansasLH State Tr Num: 38936 State Status: Approved-Closed Reviewer(s): Linda Bird Disposition Date: 05/14/2008 Disposition Status: Approved Implementation Date: State Filing Description: General Information Project Name: Project Number: Requested Filing Mode: Explanation for Combination/Other: Submission Type: New Submission Overall Rate Impact: Filing Status Changed: 05/14/2008 State Status Changed: 05/14/2008 Corresponding Filing Tracking Number: Status of Filing in Domicile: Pending Date Approved in Domicile: Domicile Status Comments: Pending Market Type: Individual Group Market Size: Group Market Type: Deemer Date: Filing Description: Enclosed please find whole life insurance application form #12-82-040. This form is new and will replace form #11-82192, which was approved by your Department on May 28, 2002.. The only change to the previously approved form is the deletion of the line for the applicant's social security number, and updated fraud statements; the remainder of the form remains unchanged. This application will be used with individual whole life policy form series 12-82-010(REV), which was approved by your Department on 9/21/05. Created by SERFF on 05/14/2008 10:13 AM SERFF Tracking Number: BNLC-125613682 State: Arkansas Filing Company: Colonial Penn Life Insurance Company State Tracking Number: 38936 TOI: L07I Individual Life - Whole Sub-TOI: L07I.121 Graded Premium - Single Life Product Name: Whole Life Application Project Name/Number: / Company Tracking Number: Areas bracketed or presented in “John Doe” fashion are intended to be variable. Such variability includes name, address, phone number, age, date of birth, sex, issue date, effective date, premium, premium mode, policy type, and benefit amounts and values. We also request variability for any fraud statement changes required by law. The enclosed form is in final printed format, subject only to minor changes in ink, color, paper stock, company logo and logo type, border design, margin and positioning. Following approval, the new form will be used in place of the old application as soon as administratively possible. I trust this filing is in order, but should additional information be needed please contact me. Thank you for your courtesy. Company and Contact Filing Contact Information Karen Schussler, Associate Analyst kschussler@colpenn.com 399 Market Street (215) 928-6420 [Phone] Philadelphia, PA 19181 (215) 928-6431[FAX] Filing Company Information Colonial Penn Life Insurance Company CoCode: 62065 State of Domicile: Pennsylvania 399 Market Street Group Code: 233 Company Type: Life/Health Philadelphia, PA 19181 Group Name: State ID Number: (215) 928-8688 ext. [Phone] FEIN Number: 23-1628836 --------- Filing Fees Fee Required? Yes Fee Amount: $50.00 Retaliatory? No Fee Explanation: Application - $50.00 Per Company: No Created by SERFF on 05/14/2008 10:13 AM SERFF Tracking Number: BNLC-125613682 State: Arkansas Filing Company: Colonial Penn Life Insurance Company State Tracking Number: 38936 TOI: L07I Individual Life - Whole Sub-TOI: L07I.121 Graded Premium - Single Life Product Name: Whole Life Application Project Name/Number: / Company Tracking Number: COMPANY AMOUNT DATE PROCESSED TRANSACTION # Colonial Penn Life Insurance Company $50.00 05/09/2008 20191298 Created by SERFF on 05/14/2008 10:13 AM SERFF Tracking Number: BNLC-125613682 State: Arkansas Filing Company: Colonial Penn Life Insurance Company State Tracking Number: 38936 TOI: L07I Individual Life - Whole Sub-TOI: L07I.121 Graded Premium - Single Life Product Name: Whole Life Application Project Name/Number: / Company Tracking Number: Correspondence Summary Dispositions Status Created By Created On Date Submitted Approved Linda Bird 05/14/2008 05/14/2008 Created by SERFF on 05/14/2008 10:13 AM SERFF Tracking Number: BNLC-125613682 State: Arkansas Filing Company: Colonial Penn Life Insurance Company State Tracking Number: 38936 TOI: L07I Individual Life - Whole Sub-TOI: L07I.121 Graded Premium - Single Life Product Name: Whole Life Application Project Name/Number: / Company Tracking Number: Disposition Disposition Date: 05/14/2008 Implementation Date: Status: Approved Comment: Rate data does NOT apply to filing. Created by SERFF on 05/14/2008 10:13 AM SERFF Tracking Number: BNLC-125613682 State: Arkansas Filing Company: Colonial Penn Life Insurance Company State Tracking Number: 38936 TOI: L07I Individual Life - Whole Sub-TOI: L07I.121 Graded Premium - Single Life Product Name: Whole Life Application Project Name/Number: / Company Tracking Number: Item Type Supporting Document Item Name Certification/Notice Supporting Document Application Yes Supporting Document Life & Annuity - Acturial Memo No Form application Yes Created by SERFF on 05/14/2008 10:13 AM Item Status Public Access Yes SERFF Tracking Number: BNLC-125613682 State: Arkansas Filing Company: Colonial Penn Life Insurance Company State Tracking Number: 38936 TOI: L07I Individual Life - Whole Sub-TOI: L07I.121 Graded Premium - Single Life Product Name: Whole Life Application Project Name/Number: / Company Tracking Number: Form Schedule Lead Form Number: 12-82-040 Review Form Form Type Form Name Status Number 12-82-040 Policy/Cont application ract/Fratern al Certificate: Amendmen t, Insert Page, Endorseme nt or Rider Action Action Specific Readability Attachment 54 12-82-040.pdf Data Initial Created by SERFF on 05/14/2008 10:13 AM SERFF Tracking Number: BNLC-125613682 State: Arkansas Filing Company: Colonial Penn Life Insurance Company State Tracking Number: 38936 TOI: L07I Individual Life - Whole Sub-TOI: L07I.121 Graded Premium - Single Life Product Name: Whole Life Application Project Name/Number: / Company Tracking Number: Rate Information Rate data does NOT apply to filing. Created by SERFF on 05/14/2008 10:13 AM SERFF Tracking Number: BNLC-125613682 State: Arkansas Filing Company: Colonial Penn Life Insurance Company State Tracking Number: 38936 TOI: L07I Individual Life - Whole Sub-TOI: L07I.121 Graded Premium - Single Life Product Name: Whole Life Application Project Name/Number: / Company Tracking Number: Supporting Document Schedules Review Status: Satisfied -Name: Certification/Notice 04/17/2008 Comments: Attachment: AR Flesch.pdf Review Status: Satisfied -Name: Application 04/17/2008 Comments: Attachment: 12-82-040.pdf Review Status: Bypassed -Name: Life & Annuity - Acturial Memo Bypass Reason: N/A - Application filing only. Comments: Created by SERFF on 05/14/2008 10:13 AM 04/17/2008

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