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SERFF Status: Closed State Tr Num: EFT $25 Made/Occurrence

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Project Name/Number: GL Forms In Response To Terrorism Risk Insurance Program Reauthorization Act Of 2007/ GL-AR Filing at a Glance Company: QBE Insurance Corporation Product Name: GL Forms In
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Project Name/Number: GL Forms In Response To Terrorism Risk Insurance Program Reauthorization Act Of 2007/ GL-AR Filing at a Glance Company: QBE Insurance Corporation Product Name: GL Forms In Response To SERFF Tr Num: QBEC State: Arkansas Terrorism Risk Insurance Program Reauthorization Act Of 2007 TOI: 17.0 Other Liability - Claims SERFF Status: Closed State Tr Num: EFT $25 Made/Occurrence Sub-TOI: Commercial General Liability Co Tr Num: State Status: Fees verified and received Filing Type: Form Co Status: Reviewer(s): Betty Montesi, Edith Roberts, Brittany Yielding Author: Marsha Layton Disposition Date: 03/28/2008 Date Submitted: 03/25/2008 Disposition Status: Approved Effective Date Requested (New): 06/01/2008 Effective Date (New): Effective Date Requested (Renewal): 06/01/2008 Effective Date (Renewal): State Filing Description: General Information Project Name: GL Forms In Response To Terrorism Risk Insurance Program Reauthorization Act Of 2007 Project Number: GL-AR Reference Organization: ISO Reference Title: Filing Status Changed: 03/28/2008 State Status Changed: 03/28/2008 Corresponding Filing Tracking Number: Status of Filing in Domicile: Pending Domicile Status Comments: Reference Number: CL-2007-OTRL1 Advisory Org. Circular: LI-GL Deemer Date: Filing Description: QBE is a subscriber of Insurance Services Office for General Liability Forms. ISO does not file on behalf of QBE. In response to the Terrorism Risk Insurance Program Reauthorization Act Of 2007, QBE is submitting for your approval the adoption of the ISO forms filing CL-2007-OTRL1. Project Name/Number: GL Forms In Response To Terrorism Risk Insurance Program Reauthorization Act Of 2007/ GL-AR We will be implementing these revisions for all policies effective on and after June 1, Company and Contact Filing Contact Information Marsha Layton, Senior Compliance Analyst 2230 Village Mall Drive (419) [Phone] Mansfield, OH (419) [FAX] Filing Company Information QBE Insurance Corporation CoCode: State of Domicile: Pennsylvania 88 Pine Street - 16th Floor Group Code: 796 Company Type: New York, NY Group Name: QBE Insurance State ID Number: Group (212) ext. [Phone] FEIN Number: Filing Fees Fee Required? Yes Fee Amount: $25.00 Retaliatory? No Fee Explanation: $25.00 Reference Forms Filing Per Company: No COMPANY AMOUNT DATE PROCESSED TRANSACTION # QBE Insurance Corporation $ /25/ Project Name/Number: GL Forms In Response To Terrorism Risk Insurance Program Reauthorization Act Of 2007/ GL-AR Correspondence Summary Dispositions Status Created By Created On Date Submitted Approved Edith Roberts 03/28/ /28/2008 Project Name/Number: Disposition GL Forms In Response To Terrorism Risk Insurance Program Reauthorization Act Of 2007/ GL-AR Disposition Date: 03/28/2008 Effective Date (New): Effective Date (Renewal): Status: Approved Comment: Rate data does NOT apply to filing. Project Name/Number: GL Forms In Response To Terrorism Risk Insurance Program Reauthorization Act Of 2007/ GL-AR Item Type Item Name Item Status Public Access Supporting Document Uniform Transmittal Document-Property & Approved Yes Casualty Supporting Document Cover Letter Approved Yes Project Name/Number: GL Forms In Response To Terrorism Risk Insurance Program Reauthorization Act Of 2007/ GL-AR Rate Information Rate data does NOT apply to filing. Project Name/Number: GL Forms In Response To Terrorism Risk Insurance Program Reauthorization Act Of 2007/ GL-AR Supporting Document Schedules Satisfied -Name: Uniform Transmittal Document- Property & Casualty Comments: Attachment: AR GL NAIC PC Trans Doc Forms Response To TRIPRA.PDF Review Status: Approved 03/28/2008 Review Status: Satisfied -Name: Cover Letter Approved 03/28/2008 Comments: Attachment: AR GL Forms Response To Terrorism Risk Insurance Act Progr.PDF Effective March 1, 2007 Property & Casualty Transmittal Document 1. Reserved for Insurance Dept. Use Only 2. Insurance Department Use only a. Date the filing is received: b. Analyst: c. Disposition: d. Date of disposition of the filing: e. Effective date of filing: New Business Renewal Business f. State Filing #: g. SERFF Filing #: h. Subject Codes 3. Group Name Group NAIC # QBE Insurance Corporation Company Name(s) Domicile NAIC # FEIN # State # QBE Insurance Corporation PA Company Tracking Number GL-AR Contact Info of Filer(s) or Corporate Officer(s) [include toll-free number] 6. Name and address Title Telephone #s FAX # Marsha Layton 2230 Village Mall Drive Suite 1 Mansfield, OH Senior Product Compliance/ Development Analyst qbeamericas.com 7. Signature of authorized filer Marsha Layton 8. Please print name of authorized filer Marsha Layton Filing information (see General Instructions for descriptions of these fields) 9. Type of Insurance (TOI) 17.0 Other Liability Occ/Claims Made 10. Sub-Type of Insurance (Sub-TOI) Commercial General Liability 11. State Specific Product code(s)(if applicable)[see State Specific Requirements] N/A 12. Company Program Title (Marketing title) MidStates Contractors 13. Filing Type [ ] Rate/Loss Cost [ ] Rules [ ] Rates/Rules [ X ] Forms [ ] Combination Rates/Rules/Forms [ ] Withdrawal[ ] Other (give description) 14. Effective Date(s) Requested New: 06/01/08 Renewal: 06/01/ Reference Filing? [ X ] Yes [ ] No 16. Reference Organization (if applicable) ISO 17. Reference Organization # & Title CL-2007-OTRL1 18. Company s Date of Filing 03/25/ Status of filing in domicile [ ] Not Filed [ X ] Pending [ ] Authorized [ ] Disapproved PC TD-1 pg 1 of 2 Property & Casualty Transmittal Document 20. This filing transmittal is part of Company Tracking # GL-AR 21. Filing Description [This area can be used in lieu of a cover letter or filing memorandum and is free-form text] QBE is a subscriber of Insurance Services Office for General Liability Forms. ISO does not file on behalf of QBE. In response to the Terrorism Risk Insurance Program Reauthorization Act of 2007, QBE is submitting for your approval the adoption of the ISO forms filing CL-2007-OTRL1. We will be implementing these revisions for all policies effective on and after June 1, Filing Fees (Filer must provide check # and fee amount if applicable) [If a state requires you to show how you calculated your filing fees, place that calculation below] Check #: EFT Amount: $25.00 Refer to each state s checklist for additional state specific requirements or instructions on calculating fees. ***Refer to the each state s checklist for additional state specific requirements (i.e. # of additional copies required, other state specific forms, etc.) PC TD-1 pg 2 of National Association of Insurance Commissioners Effective March 1, 2007 FORM FILING SCHEDULE (This form must be provided ONLY when making a filing that includes forms) (Do not refer to the body of the filing for the forms listing, unless allowed by state.) 1. This filing transmittal is part of Company Tracking # GL-AR This filing corresponds to rate/rule filing number (Company tracking number of rate/rule filing, if applicable) Form Name /Description/Synopsis As outlined under ISO circular LI-GL & approved under ISO circular LI-GL Form # Include edition date Replacement Or withdrawn? GL-AR If replacement, give form # it replaces Previous state filing number, if required by state PC FFS National Association of Insurance Commissioners March 25, 2008 Honorable Julie Benafield Bowman Commissioner of Insurance Arkansas Insurance Department 1200 West Third Street Little Rock, Arkansas QBE Insurance Corporation NAIC # ; FEIN # DIVISION SIX GENERAL LIABILITY MidStates Contractors Program Filing of QBE Forms In Response to Terrorism Risk Insurance Program Reauthorization Act of 2007 Company ID Filing No: GL-AR QBE is a subscriber of Insurance Services Office for General Liability Forms. ISO does not file on behalf of QBE. In response to the Terrorism Risk Insurance Program Reauthorization Act of 2007, QBE is submitting for your approval the adoption of the ISO forms filing CL-2007-OTRL1. We will be implementing these revisions for all policies effective on and after June 1, This filing is being submitted via SERFF. Your acknowledgement of this filing would be greatly appreciated. If you have any questions, please feel free to contact me at 2230 Village Mall Drive, Suite 1, Mansfield, OH or by phone at (419) ext. 16 or by at Sincerely, Marsha Layton Marsha Layton Senior Product Compliance/Development Analyst Enc: Filing Fee - $25.00
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