How to report a Balance Billing Protect Act settlement (Appendix D)

This settlement reporting form is required by the Office of the Insurance Commissioner (OIC) for parties who have settled proceedings under RCW 48.49.040 (leg.wa.gov). This mandatory form is referred to as “Appendix D” in WAC 284-43B-100 (leg.wa.gov). Submission of this form satisfies the reporting requirements under RCW 48.49.040(7) (leg.wa.gov).

When to submit this form?

• No later than three business days after the date of the settlement agreement.
• The form must be submitted even if an initiating party’s arbitration initiation request form (AIRF) is under review by the OIC, an AIRF number has not yet been assigned, and or an arbitrator has not yet been assigned.

How to complete and submit this form

1. After carefully reading and following the instructions on this page, download the settlement reporting form (PDF, 255.84 KB).
2. Fill in all required information (i.e., initiating party information, dispute resolution information, etc.). If there is no AIRF number (OIC tracking number) note, “not assigned yet.”
3. Complete the form, which must be signed by both parties.
4. File electronically by uploading the form as a .PDF attachment to the contact the arbitration team form.

To submit a settlement reporting form for more than one arbitration proceeding involving the same parties

Parties may submit a spreadsheet containing all the required information for each claim that has been settled, as follows:

• The initiating party’s information and the parties' signatures must be indicated on the form; signatures may be electronic. The rest of the fields may say “see attached”
• The spreadsheet columns should match the form fields on the settlement reporting form (i.e., date of settlement, OIC tracking number, name of carrier, etc.)
• The spreadsheet and form should be saved to a single .PDF signed by the parties electronically.