An application for a certificate of authority to operate a prepaid limited health service
organization must be filed with the commissioner on a form prescribed by the commissioner.
Such application must be verified by an officer or authorized representative of the applicant and
must set forth, or be accompanied by, the following:
1.A copy of the applicant's basic organizational document, such as the articles of
incorporation, articles of association, partnership agreement, trust agreement, or other
applicable documents and all amendments to such documents.
2.A copy of all bylaws, rules and regulations, or similar documents, if any, regulating the
conduct of the applicant's internal affairs.
3.A list of the names, addresses, official positions, and biographical information of the
individ
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An application for a certificate of authority to operate a prepaid limited health service
organization must be filed with the commissioner on a form prescribed by the commissioner.
Such application must be verified by an officer or authorized representative of the applicant and
must set forth, or be accompanied by, the following:
1. A copy of the applicant's basic organizational document, such as the articles of
incorporation, articles of association, partnership agreement, trust agreement, or other
applicable documents and all amendments to such documents.
2. A copy of all bylaws, rules and regulations, or similar documents, if any, regulating the
conduct of the applicant's internal affairs.
3. A list of the names, addresses, official positions, and biographical information of the
individuals who are responsible for conducting the applicant's affairs, including all
members of the board of directors, board of trustees, executive committee, or other
governing board or committee, the principal officers, and any person or entity owning
or having the right to acquire ten percent or more of the voting securities of the
applicant, and the partners or members in the case of a partnership or association.
4. A statement generally describing the applicant, its facilities, personnel, and the limited
health service or services to be offered.
5. A copy of the form of any contract made or to be made between the applicant and any
providers regarding the provision of limited health services to enrollees.
6. A copy of the form of any contract made or to be made between the applicant and any
person listed in subsection 3.
7. A copy of the form of any contract made or to be made between the applicant and any
person, corporation, partnership, or other entity for the performance on the applicant's
behalf of any functions, including the following:
a. Marketing and enrollment.
b. Administration.
c. Investment management.
d. Subcontracting for the provision of the limited health service to enrollees.
8. A copy of the form of any contract which is to be issued to employers, unions, trustees,
or other organizations or individuals and a copy of any form of evidence of coverage to
be issued to subscribers or enrollees.
9. A copy of the applicant's most recent financial statements audited by independent
certified public accountants. If the financial affairs of the applicant's parent company
are audited by independent certified public accountants but those of the applicant are
not, then a copy of the most recent audited financial statement of the applicant's
parent company, certified by an independent certified public accountant, attached to
which will be consolidating financial statements of the applicant, satisfies this
requirement unless the commissioner determines that additional or more recent
financial information is required for the proper administration of this chapter.
10. A copy of the applicant's financial plan, including a three-year projection of anticipated
operating results, a statement of the sources of working capital, and any other sources
of funding and provisions for contingencies.
11. A schedule of rates and charges.
12. A description of the proposed method of marketing.
13. A statement acknowledging that all lawful process in any legal action or proceeding
against the applicant on a cause of action arising in this state is valid if served upon
the commissioner.
14. A description of the complaint procedures to be established and maintained as
required under section 26.1-17.1-12.
15. A description of the quality assessment and utilization review procedures to be utilized
by the applicant.
16. A description of how the applicant will comply with section 26.1-17.1-17.
17. The fee for issuance of a certificate of authority provided in section 26.1-17.1-23.
18. Such other information as the commissioner may reasonably require to make the
determinations required by this chapter.