Compilation of Rules and Regulations of the State of Georgia › Department 120 - OFFICE OF COMMISSIONER OF INSURANCE, SAFETY FIRE COMMISSIONER AND INDUSTRIAL LOAN COMMISSIONER › Chapter 120-2 - RULES OF COMMISSIONER OF INSURANCE › Subject 120-2-50 - MULTIPLE EMPLOYER SELF-INSURED HEALTH PLANS › Rule 120-2-50-.16 - Severability

Current through Rules and Regulations filed through June 27, 2024
If any provision of this Regulation, or the application
				  thereof to any person or circumstance, is held invalid by a court of competent
				  jurisdiction, the remainder of the Regulation and the applicability of such
				  provision to other persons or circumstances shall not be affected
				  thereby.
EXHIBIT A
OFFICE OF COMMISSIONER OF INSURANCE STATE OF GEORGIA
APPLICATION FOR LICENSE FOR MULTIPLE EMPLOYER SELF-INSURED
				  HEALTH PLAN
To the Commissioner of Insurance of the State of Georgia:
				  ____________________________________________________________
(Name of Plan) domiciled in the State of ___________________
				  and whose home or principal office is located in the City of ______________ and
				  State of ___________________ by its Trustees hereby make application for a
				  license to transact business as a Multiple Employer Self-Insured Health Plan in
				  the State of Georgia for the period ending June 30, 19_____.
1. Name of Plan and Federal Employer Identification (EIN)
				  number ______________.
2. Street Address
				  __________________________________________
3. Post Office Box (if applicable)
				  _________________________
4. City _____________________ State ________________________
				  Zip _______________
5. Date plan organized _____________________________________
				  Has the plan been in continuous operation since that time?
Yes _______ No ______ If "no," explain why not___________
				  ________________________________________________________
				  ________________________________________________________
6. Form of Organization: __________________________________
				  ________________________________________________________ (Trust, Corporation,
				  Partnership, etc.)
7. Date Plan began business: ______________________________
				  ________________________________________________________
8. Number of employers participating ______________________
				  ________________________________________________________
9. Type(s) of business(es) of participating employers _____
				  ________________________________________________________
				  ________________________________________________________
				  ________________________________________________________
10. Name and address of sponsoring organization or
				  association, if any ____________________________________
				  ________________________________________________________
				  ________________________________________________________
11. Number of employees covered ____________________________
				  ________________________________________________________
				  ________________________________________________________
12. Give the names and addresses of plan trustees, the
				  employers which they represent, and the licensed surety company(ies) by which
				  they are bonded (including bond numbers):
Name Address Employer Surety Bond
Represented Name Number
a.
				  ________________________________________________________
b.
				  ________________________________________________________
c.
				  ________________________________________________________
d.
				  ________________________________________________________
e.
				  ________________________________________________________
f.
				  ________________________________________________________
g.
				  ________________________________________________________
13. Name and address of licensed investment manager ________
				  ________________________________________________________
				  ________________________________________________________
14. Name and address of plan administrator, if any _________
				  ________________________________________________________
				  ________________________________________________________
Describe the duties which the administrator performs on
				  behalf of the plan _____________________________________
				  ________________________________________________________
				  ________________________________________________________
15. In what states is the administrator licensed? (Please
				  provide all license numbers)____________________________
				  ________________________________________________________
				  ________________________________________________________
16. Has this plan ever been the subject of any administrative
				  investigation or disciplinary action, by any insurance regulatory authority?
				  Yes ______ No _____.
If "yes", provide details and attach copies of all orders and
				  pertinent documentation.
17. Has this plan ever surrendered a license or entered into
				  a Consent Order to avoid disciplinary proceedings by any insurance regulatory
				  authority? Yes _______ No _____. If "yes", provide details and attach copies of
				  all surrenders, orders, and other pertinent documentation.
18. List all states other than Georgia where the plan
				  transacts business _____________________________________
				  ________________________________________________________
				  ________________________________________________________
				  ________________________________________________________
19. List all states other than Georgia in which the plan is
				  licensed in any manner by any regulatory authority, giving the type of license
				  held and the name of the official or agency issuing the license:
State Type of license Issuing official or agency
a.
				  _____________________________________________________
b.
				  _____________________________________________________
c.
				  _____________________________________________________
d. _____________________________________________________
(use additional page if necessary)
20. Identify benefits provided employees:
Accident and Health () Dental ()
Short-Term Disability () Other ()
Specify
				  ________________________________________________
21. State the reasons the plan is applying for a Georgia
				  license, a description of exactly how the plan proposes to develop and
				  supervise its operations in Georgia, the name, title and qualifications of the
				  person who will be responsible for the plan's operation in Georgia, and the
				  location of and a description of the office facilities that will be provided by
				  the plan in Georgia.
________________________________________________________
________________________________________________________
________________________________________________________
________________________________________________________
________________________________________________________
________________________________________________________
________________________________________________________
________________________________________________________
(Attach additional sheets if needed)
22. Attached to this Application, and incorporated herein by
				  reference, are the following:
a. Copy of the plan's bylaws, all schedules of benefits, and
				  all management, administration and trust agreements which the plan has made or
				  proposes to make for the conduct of its business and affairs, certified by a
				  majority of the trustees.
b. An audited financial statement, prepared by a certified
				  public accountant (CPA), on form ME-3.
c. A complete list of the names, addresses, Federal Employer
				  Identification Numbers, and telephone numbers of all employers participating in
				  the plan, and the number of employees of each employer.
d. A copy of individual and aggregate excess stop-loss policy
				  or policies covering the plan.
e. A power of attorney appointing a Georgia resident to
				  receive legal process (Form ME-5).
f. Proof of bonding of trustees as required in Rule
				  120-2-50-.09.
g. Proposed disclosure statement as required in Rule
				  120-2-50-.03.
h. A check for the applicable filing fee, made payable to the
				  Georgia Commissioner of Insurance.
CERTIFICATION
We, ____________________________________________________
				  ____________________________________________________________ __________, the
				  undersigned, constituting a majority of the Trustees of
				  ________________________________________________
				  ____________________________________________________________
				  ____________________________________________________________
(Name of Multiple Employer Self-Insured Health Plan) swear
				  that to the best of our knowledge and belief, the statements contained in the
				  foregoing application for license, including all documents attached hereto, are
				  true and complete.
COUNTY OF ________________
STATE OF _________________
BY: __________________
(Name of Trustee)
Sworn to before me this _______ day of _______________
				  19___.
_____________________________
NOTARY PUBLIC
My Commission Expires
______________________________
COUNTY OF _____________
STATE OF ________________
BY: __________________
(Name of Trustee)
Sworn to before me this
_______ day of _______________ 19 _____.
_____________________________
NOTARY PUBLIC
My Commission Expires ______________________________
COUNTY OF ____________________
STATE OF _____________________
BY: __________________
(Name of Trustee)
Sworn to before me this
_______ day of _______________ 19 ______.
_____________________________
NOTARY PUBLIC
My Commission Expires _____________________________
COUNTY OF _____________
STATE OF _______________
BY: __________________
(Name of Trustee)
Sworn to before me this
_______ day of _______________ 19_______.
_____________________________
NOTARY PUBLIC
My Commission Expires _____________________________
EXHIBIT B
OFFICE OF COMMISSIONER OF INSURANCE STATE OF GEORGIA
FINANCIAL STATEMENT MULTIPLE EMPLOYER SELF-INSURED HEALTH
				  PLANS
INSTRUCTIONS
____________________________________________________________
				  ___________________________________________________________
General Instructions.
The financial statement
				  consists of four basic statements:
1) balance sheet;
2) statement of income, expenses and surplus;
3) statement of changes in financial position; and
4) schedule of investments.
A plan's financial statements must be in conformance with
				  these instructions. They may deviate from the prescribed format for the purpose
				  of increasing the quality of the information. For example, an entry may be
				  broken into more detailed subparts. Blank lines are provided for this purpose,
				  or for adding entries. In general, whenever the meaning of an entry may be
				  unclear, a footnote explanation should be provided. Footnotes are an integral
				  part of the financial statement.
____________________________________________________________
____________________________________________________________
BALANCE SHEET
1.
Cash on hand and on deposit.
This is coin,
				  currency, and the balance in accounts with banks or other financial
				  institutions.
2.
Bonds.
This is the value of all fixed period,
				  interest bearing securities, including bonds, certificates of deposit,
				  commercial paper, and similar investments. Such securities shall be valued at
				  their actual cost, excluding accrued interest.
3.
Stocks.
This is the value of all securities
				  representing equity interest in commercial entities, including common stock and
				  preferred stock. Such securities shall be valued at their market value.
4-6. List here any investments not fitting the other
				  categories in this section.
7. Enter the total of items 1 through 6.
8.
Premiums due and unpaid.
This is the amount
				  of premiums owed by plan members but not yet paid. Premium should not be
				  considered due until the inception of the period to which the premium
				  applies.
9.
Assessments due and unpaid.
This is the
				  amount of assessments owed by plan members but not yet paid. Assessments may be
				  to increase plan surplus or to correct a deficit.
10.
Penalties due and unpaid.
This is the amount
				  of penalties levied against plan members pursuant to the plan's rules and
				  bylaws, but not yet paid.
11.
Investment income due and accrued.
This is
				  the amount of dividends declared and interest accrued on plan investments, but
				  not yet received or credited to plan accounts.
12.
Third party reimbursements receivable.
This
				  is the amount owed the plan on account of losses it has paid, for which it is
				  entitled to reimbursement through subrogation, coordination of benefits, return
				  of overpayments, or similar recovery actions.
13.
Amounts recoverable from stop loss insurers.
This is the amount the plan is entitled to recover under its
				  stop loss insurance, but which has not yet been paid. This is the total
				  recoverable under both individual and aggregate access coverage, based on the
				  plan's current level of losses paid and incurred but unpaid claims.
14.
Prepaid expenses.
This is the portion of any
				  expenses which the plan has paid, for which the value has not yet been
				  received. Prepaid expenses for services applicable to fixed periods of time,
				  such as stop loss insurance, shall be valued according to the percentage of
				  unelapsed time in the period to which the payment is applicable. Other prepaid
				  expenses shall be valued according to the portion of the service which has not
				  yet been received.
15-16. List here any assets not fitting the other categories
				  in this section.
17. Enter the total of items 8 through 16.
18. Enter the total of items 7 and 17.
19.
Reserve for unearned and advance premiums.
This is the portion of all premiums which have not yet been earned. Premium is
				  earned as the period of time to which the premium applies elapses. This reserve
				  includes:
(A) All advanced premiums, namely, premiums paid prior to the
				  inception of the period to which they apply.
(B) For coverage in force, the percentage of premium
				  corresponding to the unelapsed time in the period to which the premium applies.
				  For example, if premiums are paid monthly, half-way through any month one-half
				  of the corresponding premium payment would be unearned.
20.
Reserve for outstanding losses - reported.
This is the plan's best estimate of the amount it will be obligated to pay for
				  known loss occurrences or continuing courses of treatment. This reserve
				  includes:
(A) Claims awaiting payment, for which checks have not yet
				  been issued.
(B) The estimated final cost of claims subject to
				  investigation, litigation, or negotiations (explain in footnote). For claims
				  where liability is disputed or the amount uncertain, the estimated cost should
				  be a weighted value of the possible outcomes. For example, if there is a 51%
				  chance the plan will win a dispute and owe nothing, but a 49% chance it will
				  lose and owe $10,000, the estimated cost should be closer to $5,000 than to
				  zero.
(C) The estimated cost associated with covered persons
				  undergoing a continuing course of treatment or a continuing disability for
				  which the plan will likely be liable, notwithstanding that treatment has not
				  yet been provided or that the period of disability has not yet occurred. For
				  example, a person covered by the plan develops cancer and will undergo a
				  lengthy course of treatment. If it is likely that the plan will continue to
				  have responsibility for the person during the course of treatment, an
				  appropriate reserve should be established.
21.
Reserve for outstanding losses - IBNR.
This
				  is the plan's best estimate of the amount it will be obligated to pay for loss
				  occurrences that have not yet been reported (incurred but not reported). At any
				  given time, persons covered by the plan will be incurring treatment and
				  submitting bills or becoming disabled, and claims staff will be at various
				  stages of evaluating claims that have been received. The IBNR reserve should be
				  reasonably sufficient to cover such outstanding liability, based on staff
				  judgment and the plan's actual experience overtime.
22. List here any reserve not fitting the other categories in
				  this section.
23. Enter the total of items 19 through 22.
24.
Stop loss premiums due and unpaid.
This is
				  the amount of all stop loss premiums, for individual excess, aggregate excess,
				  and incurred runoff excess if applicable, that the plan owes but has not yet
				  paid.
25.
Stop loss aggregate advancement.
This
				  applies only to plans with an aggregate advancement clause in their stop loss
				  insurance contract. This is the amount of funds advanced or loaned to the plan
				  from the stop loss insurer, that have not yet been repaid, or that have not yet
				  been determined to be an actual obligation of the aggregate excess stop loss
				  insurer.
26.
Commissions due or accrued.
This is the
				  amount of commissions to agents or brokers that the plan owes but has not yet
				  paid.
27.
Other expenses due or accrued.
This is the
				  amount of all expenses not listed elsewhere that the plan owes but has not yet
				  paid.
28.
Georgia license fees due or accrued.
This is
				  the amount of license fees that the plan owes to the State of Georgia but has
				  not yet paid.
29.
Federal income taxes due or accrued.
This is
				  the amount of federal taxes on the plan's income that the plan owes but has not
				  yet paid.
30.
Federal capital gains taxes due or accrued.
This is the amount of federal taxes on capital gains on plan
				  investment transactions, that the plan owes but has not yet paid.
31.
Dividends declared and unpaid.
This is the
				  amount of dividends that have been declared, but that have not yet been paid to
				  or claimed by members.
32-34. List here any liabilities not fitting the other
				  categories in this section.
35. Enter the total of items 24 through 34.
36. Enter the total of items 23 and 35.
37.
Contributed surplus.
This is the amount
				  contributed by the members to provide capital for operation, to correct a
				  deficit; to increase the plan's working capital to forestall a deficit; or to
				  otherwise ease operations.
38.
Retained earnings.
This is the amount of
				  plan earnings from operations and unrealized capital gains that is retained and
				  not paid out as dividends. This amount is initially zero, and is subsequently
				  adjusted by each year's statement of income, expenses and surplus, item
				  38.
39. List here any surplus item not fitting the other
				  categories in this section.
40. Enter the total of items 37 through 39.
41. Enter the total of items 36 and 40.
STATEMENT OF INCOME, EXPENSES AND SURPLUS
This statement contemplates that income and expenses will be
				  calculated on an accrual basis, rather than a cash basis.
For income, this generally means that income is recognized
				  for the current fund year if the service was provided or the payment was earned
				  during the fund year, regardless of whether cash has been received. For
				  expenses, this generally means that losses or expenses are recognized for the
				  current fund year if the obligation was incurred during the fund year,
				  regardless of whether cash as been paid. Even if not explicitly stated in each
				  instruction, all income and expenses should be taken to apply to transactions
				  occurring during the current fund year.
1.
Gross premiums written.
This is the amount of
				  premiums written by the plan for coverage during the current fund year. This
				  amount should be net of any discounts or adjustments to premium. Premium should
				  not be considered written or booked until the inception of the period to which
				  the premium applies.
2.
Individual excess stop expense.
This is the
				  amount of premiums paid or incurred for individual excess stop loss
				  insurance.
3.
Aggregate excess stop loss expense.
This is
				  the amount of premiums paid or incurred for aggregate excess stop loss
				  insurance, including extended or runoff aggregate excess coverage.
4.
Change in reserve for unearned and advance
premiums.
This is the net change in the amount reported one year
				  ago on line 19 of the balance sheet. This and items 9, 10, 38, and 39 are
				  negative entries only if the net change is an increase, otherwise they would be
				  positive.
5. Enter the total of items 1 through 4.
6.
Losses paid.
This is the total amount of
				  losses (claims) paid during the current fund year.
7.
Third party reimbursements.
This is the
				  amount determined during the current fund year of reimbursements owed to the
				  plan and which the plan expects to recover, through subrogation, coordination
				  of benefits, return of over payments, or similar recovery actions. Cash need
				  not have been received during the current fund year.
8.
Recovered from stop loss insurers.
This is
				  the amount determined during the current fund year of reimbursements owed to
				  the plan on account of its stop loss insurance policies. Cash need not have
				  been received during the current fund year.
9.
Change in reserve for outstanding losses -
				  reported.
This is the net change in the amount reported one year ago on
				  line 20 of the balance sheet. If there is a net increase, enter the amount as a
				  negative number. A net decrease would be a positive entry.
10.
Change in reserve for outstanding losses -
				  IBNR.
This is the net change in the amount reported one year ago on line
				  21 of the balance sheet. If there is a net increase, enter the amount as a
				  negative number. A net decrease would be a positive entry.
11. Enter the total of items 6 through 10.
12. Enter the total of items 5 and 11.
13.
Interest income.
This is the amount of
				  interest earned during the current fund year on the accounts and investments of
				  the plan.
14.
Dividend income.
This is the amount of
				  dividends earned during the current fund year on investments of the
				  plan.
15.
Net realized capital gains (losses).
This is
				  the total net gain or loss on the disposition of any plan assets during the
				  current fund year. For the purpose of calculating a net gain or loss, the base
				  value of the asset should be its carrying value on the balance sheet.
				  Unrealized capital gains reported online 36 of previous statements should not
				  be double-counted in reporting realized capital gains.
16.
Penalties assessed.
This is the amount of
				  penalties levied against plan members pursuant to the plan's rules and bylaws
				  during the current fund year.
17-18. List here any income not fitting the other categories
				  in this section.
19. Enter the total of items 13 through 18.
20. Enter the total items 12 and 19.
21.
Service company expenses.
This is the amount
				  incurred during the current fund year for the services of the plan's service
				  company and subcontractors.
22.
Financial administrator expenses.
This is
				  the amount incurred during the current fund year for the services of the plan's
				  financial administrator.
23. Agent commissions expenses. This is the amount incurred
				  during the current fund year for agent and broker commissions.
24.
Board of trustees expenses.
This is the
				  amount incurred during the current year for board of trustees expenses.
25.
Fidelity bond expenses.
This is the amount
				  incurred during the current fund year for fidelity bonds and similar
				  coverages.
26.
License fees incurred.
This is the amount
				  incurred during the current fund year for Georgia license fees.
27.
Federal capital gains taxes incurred.
This
				  is the amount of federal taxes on capital gains on plan investment transactions
				  incurred during the current fund year.
28-29. List here any expenses not fitting the other
				  categories in this section.
30. Enter the total of items 21 through 29.
31. Enter the result of subtracting item 30 from item
				  20.
32.
Federal income taxes incurred.
This is the
				  amount of federal taxes on the plan's income incurred during the current fund
				  year.
33. Enter the results of subtracting item 32 from item 31.
34.
Total surplus, end of previous year.
This is
				  the amount from item 47 of the previous year's statement of income, expenses
				  and Surplus.
35.
After tax gain from operations.
From item 33
				  of this statement.
36.
Net unrealized capital gains (losses).
This
				  is the total net gain or loss on plan assets owned as of this reporting, that
				  is, not disposed of. For the purpose of calculating a net gain or loss, the
				  base value of the asset should be whatever value it was carried at on the
				  balance sheet as of the last reporting. The initial base value would be the
				  purchase price; subsequently the balance sheet base value would be adjusted
				  each year the asset was held to reflect unrealized capital gains and losses as
				  the asset's value changes.
37.
Dividends declared.
This is the amount of
				  dividends declared by the plan during the current fund year.
38. Enter the total of items 35 through 37.
39.
Contributed surplus and assessments.
This is
				  the amount levied against or pledged by plan members during the current fund
				  year to correct a deficit and/or increase the surplus.
40-44. List here any items affecting surplus not fitting the
				  other categories in this section.
45. Enter the total of items 39 through 44.
46. Enter the total of items 38 and 45.
47. Enter the total of items 34 and 46.
STATEMENT OF CHANGES IN FINANCIAL
				  POSITION
1.
Before tax gain (loss) from operations.
This
				  is the amount from line 31 of the statement of income, expenses and
				  surplus.
2-9.
Increase (decrease) in various liabilities.
This is the net change in the amount reported one year ago on the balance sheet
				  for these liabilities. Changes in these liabilities affect income and expenses,
				  but do not affect funds.
10-11. List here any other liabilities affecting income and
				  expenses but not funds, not fitting the other categories in this
				  section.
12-16.
Decrease (increase) in various assets.
This is the net change in the amount reported one year ago on the balance sheet
				  for these assets. Changes in these assets affect income and expenses, but do
				  not affect funds.
17-18. List here any other assets affecting income and
				  expenses but not funds, not fitting the other categories in this
				  section.
19. Enter the total of items 1 through 18.
20.
Bonds.
This is the amount received upon the
				  sale, maturation, or disposition of all fixed period, interest bearing
				  securities, including bonds, certificates of deposit, commercial paper, and
				  similar investments. Such investments acquired and disposed of during the year
				  should be reported in item 22.
21.
Stocks.
This is the amount received upon the
				  sale or disposition of all securities representing equity interest in
				  commercial entities, including stock and preferred stock. Such investments
				  acquired and disposed of during the year should be reported in item 22.
22.
Net gain (loss) on investments acquired and
				  disposed of during year.
This is the total net gain or loss on assets
				  acquired and disposed of during the year. For the purpose of calculating a net
				  gain or loss, the base value of the asset should be its purchase price.
23-24. List here any investments sold, matured, or repaid,
				  not fitting the other categories in this section.
25. Enter the total of items 20 through 24.
26.
Decrease (increase) in prepaid expenses.
This is the net change in the amount reported one year ago on line 14 of the
				  balance sheet.
27.
Increase (decrease) in federal income taxes due or
				  accrued.
This is the net change in the amount reported one year ago on
				  line 31 of the balance sheet.
28.
Stop loss aggregate advancement received
				  (repaid).
This is the net amount of funds advanced or loaned to the plan
				  from the stop loss insurer that have not yet been determined to be an actual
				  obligation of the aggregate excess stop loss insurer, and funds repaid to the
				  stop loss insurer pursuant to such an advance.
29.
Contributed surplus and assessments.
This is
				  the amount of funds received during the fund year from assessments or other
				  contributions to surplus from plan members. This should be equal to the net
				  decrease (increase) in item 9 of the balance sheet, plus item 39 of the
				  statement of income, expenses and surplus.
30-31. List here any other sources of funds provided not
				  fitting the other categories in this section.
32. Enter the total of items 26 through 31.
33. Enter the total of items 19, 25, and 32.
34.
Bonds.
This is the amount expended for the
				  acquisition of all fixed period, interest bearing securities, including bonds,
				  certificates of deposit, commercial paper, and similar investments. This should
				  include the amount expensed for accrued interest, and exclude the amount
				  expended for investments acquired and disposed of during the fund year.
35.
Stocks.
This is the amount expended for the
				  acquisition of all securities representing equity interest in commercial
				  entities, including stock and preferred stock. This should exclude the amount
				  expended for investments acquired and disposed of during the fund year.
36-37. List here any investments acquired not fitting the
				  other categories in this section.
38. Enter the total of items 34 through 37.
39.
Dividends paid.
This is the amount of
				  dividends paid to members during the fund year. This should be equal to the net
				  decrease (increase) in item 31 of the balance sheet, plus item 37 of the
				  statement of income, expenses and surplus.
40-41. List here any other uses of funds not fitting the
				  other categories in this section.
42. Enter the total of items 39 through 41.
43. Enter the total of items 38 and 42.
44.
Cash on hand and on deposit, beginning of
				  year.
This is the amount from item 1 of the balance sheet as of the end
				  of the previous year.
45.
Increase (decrease) in cash.
This is the
				  result of subtracting item 43 from item 33.
46.
Cash on hand and on deposit, year to date.
This is the total of items 44 and 45.
SCHEDULE OF INVESTMENTS
No form is provided for the schedule of investments. Plans
				  should submit the required information using their own format. Please note that
				  under O.C.G.A. Chapter 33-11 and Section
				  33-50-6(3), plans
				  are restricted in the types of depositories, bonds, stocks, and other
				  investments they may employ.
Cash on hand and on deposit.
The schedule must
				  contain a description of all accounts or depositories maintained by the plan at
				  banks or other financial institutions. The description must contain:
(1) the institution's name and location;
(2) the account balance as of this reporting;
(3) the type of account;
(4) the interest rate, if any, that money in the account
				  earns;
(5) a statement as to whether funds in the account are wholly
				  or partially insured; and
(6) a statement as to which plan contractors have access to
				  the account or depository, and on what conditions.
Bonds.
The schedule must contain a description
				  of all fixed period, interest bearing securities, including bonds, certificates
				  of deposit, commercial paper, and similar investments. The description must
				  contain:
(1) the issuer's name and location;
(2) the type of security;
(3) the interest rate, and the months in which interest is
				  paid;
(4) the year of acquisition, and the security's maturity
				  month/year;
(5) the actual cost of the security, excluding accrued
				  interest;
(6) the security's par value; and
(7) the month sold or disposed of; for all securities sold or
				  disposed of during the current fund year, including securities acquired during
				  the year.
Stocks.
The schedule must contain a description
				  of all securities representing equity interest in commercial entities including
				  common stock and preferred stock. The description must contain:
(1) the entity's name and location;
(2) the type of security;
(3) the year of acquisition;
(4) the number of shares;
(5) the current market value per share;
(6) the total market value of identical securities;
(7) the actual cost of the security; and
(8) the month sold or disposed of; for all securities sold or
				  disposed of during the current fund year, including securities acquired during
				  the year.
Other investments.
The schedule must contain a
				  description of all investments not fitting the above categories. The
				  information provided about such investments should be comparable to the
				  information required above.
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EXHIBIT C
OFFICE OF COMMISSIONER OF INSURANCE STATE OF GEORGIA
BIOGRAPHICAL QUESTIONNAIRE
1. Name
				  _________________________________________________
2. Office Held
				  __________________________________________
3. Individual's Name
				  ____________________________________
Date of Birth _____________
Place of Birth____________
Social Security Number _______________________________
4. Current Residential Address
				  __________________________
5. Current Business Address
				  _____________________________
6. Residential address for past five (5) years
a. ___________________________________________________
b. ___________________________________________________
c. ___________________________________________________
d. ___________________________________________________
e. ___________________________________________________
7. Education (beyond secondary schools)
______________________________________________________
				  ______________________________________________________
				  ______________________________________________________
				  ______________________________________________________
8. Employment History. (Beginning with current employer,
				  trace back complete history. Show dates of employment, name and address of
				  company, position held, and duties.)
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
9. List any other companies which you now serve, or within
				  the past five (5) years have served, as either an officer or director. (List
				  company, position and dates.)
______________________________________________________
______________________________________________________
______________________________________________________
10. Have you ever been charged with a criminal violation
(other than traffic offense) at any time?_____________
If "yes", provide complete details.
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
11. Have you ever held any other license (except a driver's
				  license)? If "Yes", provide details as to any such license. If any such license
				  was ever suspended, revoked, or renewal thereof refused, please explain and
				  attach supporting documentation.
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
12. Have you ever been charged by any regulatory agency,
				  City, County, State or Federal, with having violated any laws, rules or
				  regulations? Has any company been so charged, allegedly as a result of any
				  action or conduct on your part? _______________ If "yes" as to either, submit
				  full details including disposition of charge.
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
_______________ 19 ____ ______________________________
Date Signature
State of __________________) ss.
County of _________________)
On the ___________________ day of, 19___, before me, a Notary
				  Public in and for the State and County aforesaid, personally appeared
				  ____________________ to me known to be the individual described in and who
				  executed the aforegoing and did make oath in due form of law that the matters
				  and facts contained in the foregoing resume are true and correct.
_______________________________
NOTARY PUBLIC
EXHIBIT D OFFICE OF COMMISSIONER OF INSURANCE STATE OF
				  GEORGIA
POWER OF ATTORNEY
KNOW ALL MEN BY THESE PRESENTS,
That the_______________ Multiple Employer Self-Insured health
				  plan (hereinafter "Plan") of _______________________ State of _________________
				  * does hereby make, constitute and appoint
				  ____________________________________________________________
				  ____________________________________________________________
Business Address
____________________________________________________________
Street # and Name (P.O. Box not acceptable)
City County Zip Code
Home Address
____________________________________________________________
(Street number and name) (City) (County) (Zip Code)
its true and lawful Attorney in and for the State of Georgia,
				  on whom all process of law, whether mense or final, against said Plan may be
				  served in any action or special proceedings against said Plan in the State of
				  Georgia, subject to and in accordance with all the provisions of the statutes
				  and laws of said State of Georgia now in force, and such other Acts as may be
				  hereafter passed amendatory thereof and supplementary thereto; and the said
				  Attorney is duly authorized and empowered as the agent of said Plan to receive
				  and accept service of process in all cases provided by the laws of the State of
				  Georgia, and such service shall be deemed valid personal service upon said
				  Plan.
* Has the above name and/or address of the appointment
				  changed since the last ME-5 was filed? Yes_____ No_____
________________________
Trustee
State of _____________________
County of ____________________
Sworn to and subscribed before me _______________this day
				  of
__________________________, 19 ____
______________________
Notary Public
EXHIBIT E
OFFICE OF COMMISSIONER OF INSURANCE STATE OF GEORGIA
APPLICATION FOR DISSOLUTION
To the Commissioner of Insurance of the State of Georgia:
				  ____________________________________________________________
(Name of Plan)
hereby applies for dissolution pursuant to O.C.G.A. Section
				  33-50-9. The following information
				  is submitted:
1. Name, address, and state of domicile.
2. Date plan was first licensed in Georgia.
3. Number of employers participating.
4. Name and address of sponsoring organization, if
				  any.
5. Number of employees covered.
6. (If applicable) Name and address of licensed insurer which
				  has made an irrevocable commitment which provides for payment of all
				  outstanding liabilities and for providing all related services, including
				  payment of claims, preparation of reports, and administration of transactions
				  associated with the period when the plan provided coverage.
The following items must be attached:
a) A current, audited financial statement, form ME-3,
				  certified by a Certified Public Accountant.
b) A current list of names, addresses, telephone numbers, and
				  current number of employees for each employer covered under the plan.
c) Evidence of an irrevocable commitment from a licensed
				  insurer, if application is made pursuant to O.C.G.A. Section
				  33-50-9(a)(2).
d) A proposed plan for distribution of assets to
				  participating employers in accordance with O.C.G.A.
Section
				  33-50-9(b).
NOTE: If the Commissioner approves this application for
				  dissolution, the plan must submit evidence satisfactory to the Commissioner
				  that said distribution has been made, within sixty (60) days of such approval.
				  Failure to submit said evidence shall be deemed to be dissolution without
				  authority.
CERTIFICATION
We, ______________________________________________________
				  ____________________________________________________________ the undersigned,
				  constituting a majority of the Trustees of
				  ____________________________________________________________ swear that to the
				  best of our knowledge and belief, the statements contained in the foregoing
				  application for dissolution, including all documents attached hereto, are true
				  and complete.
COUNTY OF_________________
STATE OF _________________
BY:____________________
(Name of Trustee)
Sworn to before me this
________day of____________
19____.
__________________________
NOTARY PUBLIC
My Commission Expires
__________________________
COUNTY OF__________________
STATE OF __________________
BY:______________________
(Name of Trustee)
Sworn to before me this
________day of_____________ 19___.
___________________________
NOTARY PUBLIC
My Commission Expires
___________________________
COUNTY OF__________________
STATE OF___________________
BY:______________________
(Name of Trustee)
Sworn to before me this
________day of____________ 19___.
__________________________
NOTARY PUBLIC
My Commission Expires __________________________
COUNTY OF_____________________
STATE OF _____________________
BY:____________________
(Name of Trustee)
Sworn to before me this
___________day of____________ 19_____.
_____________________________
NOTARY PUBLIC
My Commission Expires
_____________________________
O.C.G.A. Secs.
				  33-2-9,
				  33-50-10.