Instructions for MLR Annual Reporting Form – Cover Page Line 1 MLR Reporting Year – Enter MLR Reporting Year Line 2 Health Plan ID – Enter license health plan identification. Health insurers may leave this field blank. DMHC’s Line 3 Legal Name – Enter health plan or health Insurer legal name Line 4 Doing Business As (DBA) – Enter health plan or health insurer dba, if any Line 5 Federal Tax Exempt Status? – Please enter Yes or No
Instructions for MLR Annual Reporting Form – Cover Page Line 1 – MLR Reporting Year Enter MLR Reporting Year Line 2 – Health Plan ID Enter DMHC’s license health plan identification. Health insurers may leave this field blank. Line 3 – Legal Name Enter health plan or health Insurer legal name Line 4 – Doing Business As (DBA) Enter health plan or health insurer dba, if any Line 5 – Federal Tax Exempt Status? Please enter Yes or No
AB1962_Instruction-Yr-2015_DMHC-Final.docx