DATE OF ACCIDENT...... DATE OF DEATH. AGE AT DATE OF ACCIDENT.. CAUSE OF ACCIDENT. (OCCUPATION) ..... CLAIM NO............. DATE OF REMARRIAGE OR DEATH OF ANY DEPENDENT— STATE WHICH ONE.. * IF NON-RESIDENT, ALIEN OR PARTIAL DEPENDENT, SO STATE AT DATE OF DEATH OF DECEASED NATURE, LOCATION AND EXTENT OF INJURIES AND DEGREE OF DISABILITY*. DEGREE OF DISABILITY......%: OF... (MEMBER) *IF INJURED SUSTAINED A PERMANENT INJURY PREVIOUS TO THIS ACCIDENT, SPECIFY HERE NATURE AND EXTENT THEREOF CONDITION OF INJURED AT DATE OF VALUATION AND PHYSICIAN'S PROGNOSIS.. TO WHAT CLASS OF INJURY HAS THIS CASE BEEN ASSIGNED ON PART I.. APPENDIX X PROVISIONS OF NEW YORK LAW GOVERNING RATE MAKING AND THE ADMINISTRATION OF RATES FOR CASUALTY INSURANCE Section 141 deals with the organization of rate making associations, and prohibits discrimination. Sec. 141.-Rate making associations. The term "rate" as used in this section and sections one hundred and forty-one-a and one hundred and forty-one-b shall include all of the elements and factors forming the basis for computing the consideration for insurance. Every corporation, association, board or bureau which now exists or hereafter may be formed, and every person who maintains or hereafter may maintain a bureau or office, for the purpose of suggesting, approving or making rates to be used by more than one underwriter for insurances, including surety bonds, on property or risks of any kind located in this state, hereinafter called a "rating organization," shall file with the superintendent of insurance a copy of the articles of agreement, association or incorporation and the by-laws and all amendments thereto under which such rating organization operates or proposes to operate, together with his or its business address and a list of the members or insurance corporations represented or to be represented by it, as well as such other information concerning such rating organization and its operations as may be required by the superintendent. Every such rating organization, whether before or after the filing of the information specified in the last preceding paragraph, shall be subject to the visitation, supervision and examination of the superintendent of insurance, who shall cause to be made an examination thereof as often as he deems it expedient and at least once in three years. For such purpose he may appoint as examiners one or more competent persons, and upon such examination, he, his deputy or any examiner authorized by him shall have all the powers given to the superintendent, his deputy or any examiner authorized by him by section thirty-nine of this chapter, including the power to examine under oath the officers or agents and all persons deemed to have material information regarding the business of or manner of operation by every such rating organization. The superintendent shall make public the results of such examination and shall report to the legislature in his |