Consent to Rate

Consent to Rate Procedures

For information regarding a Consent to Rate Application Reference:

The completed application must have the following information:

  • Name and address of the Insurance Company
  • NAIC Code
  • Name and Address of the Insured
  • Description and location of the risk
  • Policy Number
  • Policy type
  • Effective date of the Endorsement
  • Manual Premium (if applicable)
  • Higher Premium Charged (if applicable)
  • Reason for Non-Standard coverage
  • Description of exposure or coverage eliminated
  • When filing a Consent to Rate form seeking to attach a pollution exclusion to liability coverage, please remember to attach a copy of all policy forms you are requesting to exclude.
  • Signature of Insured
  • Signature of the Broker or Insurance company representative

The application must be signed by all named insureds.  If the named insured is a Corporation, then only one signature is needed.  If the application is submitted by U.S mail, a stamped self addressed envelope must be provided to receive an acknowledgement.

If you have any quesitons regarding the Consent to Rate Application contact:

Kevin Gaffney
802-828-4845
Kevin.Gaffney@state.vt.us

Mail the completed Consent to Rate Application to:
Department of Financial Regulation
Insurance Rates & Forms
89 Main Street
Montpelier, VT 05620-3101 

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form-consent-rate-application.pdf15.95 KB