Please click here to download the 2017 CT Assessment Base form (pdf).

The 2017 Request for Assessment Base form is due by March 31, 2018.  All premiums reported on this form for HRA or CSEHRP should be based on Direct Earned Premiums, new or existing business in Connecticut written in 2017. The health premiums reported for HRA on this form as the CONNECTICUT COVERAGE shall correspond to those, which are contained in the National Association of Insurance Commissioners Annual Statement blank for 2017. The small employer premiums shall correspond to those premiums reported to the Connecticut Insurance Department as Small Employer Market Data.

Even if your organization did not have premiums for the year or does not write A&H insurance in Connecticut, you must respond to this request.

Note: Your filing is not complete if you do not include supporting document(s) with your form.  Submit completed forms using one of the methods listed below:

  1. Fax your reply to (860) 513-4910
  2. Email your reply to
  3. Mail your reply to:

Health Reinsurance Association
& Connecticut Small Employer Health Reinsurance Pool
c/o Pool Administrators Inc.
628 Hebron Avenue, Suite 502
Glastonbury, CT 06033
For questions regarding this form, please call Greg Sanders at 800-628-7734, ext. 229

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