Public Health Fee Assessment Report 2025

1. Click ‘Get Form’ to open the Public Health Fee Assessment Report in the editor.
2. Begin by selecting your filling status under section I, choosing either 'Domestic Insurer' or 'Health Center'.
3. In section II, enter the Reporting Entity details. Fill in your Company Name, Street Address, City, State, Zip Code, Contact Person's name, Phone number, and Email address. Ensure the email is correct as all correspondence will be sent there.
4. Proceed to section III and report the number of insured or enrolled lives in Connecticut as of May 1st. If there are none, indicate 'NONE'. Remember to exclude certain categories like Medicare.
5. In section IV, certify the report by providing your signature and printing your name and title. Make sure you are authorized to submit this certification.
6. Finally, review all entries for accuracy before submitting electronically via email or mailing it to the specified address in section V.

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