ࡱ> _^ bjbj =PccM 8<[ t(       $!$* * ?   r0TKRU 0 %T%%P* *  % :   Department of Financial Services Office of Insurance Regulation APPLICATION FOR CERTIFICATE OF AUTHORITY MULTIPLE EMPLOYER WELFARE ARRANGEMENTS CHECK LIST SECTION I - APPLICATION FEES AND FORM Company Name: Completion Item # Check List 1. Specialty insurer application fees paid ( (a) Copy of invoice included (Official Form) ( (b) Copy of check ( (c) Originals mailed to Bureau of Financial and Support Services ( 2. Association completed application for license (Official Form) ( (a) All blanks completed ( (b) Sealed by association ( (c) Signed by President (original signature) ( APPLICATION FOR CERTIFICATE OF AUTHORITY MULTIPLE EMPLOYER WELFARE ARRANGEMENTS SECTION II - LEGAL Company Name: Completion Item # Check List 1. Articles of Incorporation of the Sponsoring Association ( (a) Original certification by Florida Secretary of State ( (b) Articles with all amendments attached ( Certificate of Status from Florida Secretary of State of the Sponsoring Association ( (a) Good standing indicated ( (b) Sealed by state ( (c) Signed by proper public official ( (d) Original and one copy ( 3. Association By-Laws, Rules and Regulations, and/or Constitution ( (a) Signed and dated by association secretary ( (b) Sealed by association ( (c) Original and one copy ( 4. Trust Agreement ( Agreement signed by all trustees (Original and one copy) ( (b) Other documents specifying authority of trustees (Original and one copy) ( APPLICATION FOR CERTIFICATE OF AUTHORITY MULTIPLE EMPLOYER WELFARE ARRANGEMENTS 5. Articles of Incorporation of the Arrangement ( (a) Original and one copy ( 6. Bylaws of the Arrangement ( (a) Original and one copy ( 7. Certificate of Status of the Arrangement ( (a) Original and one copy ( APPLICATION FOR CERTIFICATE OF AUTHORITY MULTIPLE EMPLOYER WELFARE ARRANGEMENTS SECTION III - FINANCIAL AND RELATED INFORMATION Company Name: Completion Item # Check List 1. Federal form 5500 ( 2. Plan of Operations ( (a) Current operations ( 1. Number of employers ( 2. Number of employees ( 3. Number of dependents ( (b) Management ( 1. Relationship identified between arrangement's trustees and their employers ( 2. Officers' employers names and addresses ( 3. List of individuals responsible for managing funds of arrangement ( (c) Administration ( 1. TPA License attached ( 2. TPA Agreement attached ( (d) Claims adjusting and underwriting ( 1. Number of adjusters and underwriters ( 2. Plan to service billings, claims, and underwriting ( 3. Justification of underwriting criteria ( APPLICATION FOR CERTIFICATE OF AUTHORITY MULTIPLE EMPLOYER WELFARE ARRANGEMENTS 4. Special health test procedures ( (e) Marketing and growth ( 1. Marketing efforts ( 2. List of persons employed to solicit participants or adjust claims ( 3. Type of licenses or qualifications ( 4. List of individuals contracted to solicit ( 3. Fidelity bond ( 4. Excess insurance agreement ( 5. Fund balance ( 6. Feasibility study ( Addresses market potential, market penetration, and market competition ( (b) Current audited financial statements ( (c) Projected income statement ( (d) Projected cash flow analysis ( (e) Projected balance sheet ( (f) Proposed initial cash and cash reserves summary ( (g) Insolvency protection deposit requirement ( APPLICATION FOR CERTIFICATION OF AUTHORITY MULTIPLE EMPLOYER WELFARE ARRANGEMENTS SECTION IV - MANAGEMENT Company Name: Completion Item # Check List 1. Alphabetical listing of officers, directors, and trustees ( (a) Separate listing of all officers and directors for sponsoring association (Official Form) ( (b) Separate listing of trustees (Official Form) ( (c) Full names listed ( (d) Titles listed ( Biographical affidavits for each individual listed in Section IV-1 (Official Form) ( For each biographical affidavit: (a) All blanks completed ( (b) "Yes" answers explained ( (c) Contains original signature ( (d) Notarized (original) ( (e) Submitted original of each affidavit ( Authority for Release of Information forms for each individual listed in Section IV-1 (Official Form) ( For each release form: (a) Contains original signature ( (b) Notarized (original) ( APPLICATION FOR CERTIFICATE OF AUTHORITY MULTIPLE EMPLOYER WELFARE ARRANGEMENTS (c) Submitted original of each release form ( 4. Investigative Background Report for each individual listed in Section IV-1 ( (a) Investigative reporting firm contacted ( Full names given to investigative reporting firm for all individuals listed in Section IV-1 ( Arrangements made for reports to be sent directly to this Office ( (d) Evidence indicating background investigative report has been ordered for all officers, directors and trustees, dated no less than 4 weeks prior to date of application (cancelled check or letter of transmittal) ( APPLICATION FOR CERTIFICATE OF AUTHORITY MULTIPLE EMPLOYER WELFARE ARRANGEMENT SECTION V - FORMS AND RATES Company Name: Completion Item # Check List 1. Forms ( (a) 3 copies ( (b) Contain assessability language ( (c) Meet flesch score requirements ( 2. Marketing material ( (a) Advertising material ( (b) Participating employer application ( (c) Description of association support ( 3. Rates to be charged ( (a) 3 copies ( 4. 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