Iowa Administrative Code › Agency 191 - Insurance Division › Life and Health Insurance › Chapter 41 - Limited Service Organizations › Rule 191-41.10 - Application for Certificate of Authority

Current through Register Vol. 47, No. 3, July 24, 2024
The application for certificate of authority shall be in the
				  following form:
LIMITED SERVICE ORGANIZATION
APPLICATION FOR CERTIFICATE OF AUTHORITY
(Name of Limited Service Organization)
Organized as _____________________________________ under the
				  laws of the state of _________________________, makes application to the
				  commissioner of insurance for a certificate of authority to establish and
				  operate a limited service organization in compliance with Iowa Code chapter
				  514B.
Attached and made a part of this application are exhibits
				  bearing numbers corresponding to the following:
1. A copy of the basic organizational
				document of the applicant, such as the articles of incorporation, articles of
				association or other applicable documents and all of its amendments.
2. A copy of the bylaws, rules or similar
				document regulating the conduct of the internal affairs of the
				applicant.
3. A list of the names,
				addresses, and official positions of the persons who are to be responsible for
				the conduct of the affairs of the applicant, including all members of the board
				of directors, board of trustees, executive committee, or other governing board
				or committee, the principal officers if a corporation and the partners or
				members if a partnership or association.
3.1 A list of the names and addresses of each owner of 5
				  percent or more of the LSO.
4. A copy of any contract made or to be made
				between any providers and the applicant.
4.1 A copy of any contract made or to be made between the
				  applicant and any person listed in paragraph "3" above.
4.2A copy of any contract made or to be made between the
				  applicant and any person for management services.
5. A statement generally describing the LSO
				including, but not limited to, a description of its facilities and
				personnel.
6. A copy of the form of
				evidence of coverage.
7. A copy of
				the form of the group contract, if any, which is to be issued to employers,
				unions, trustees or other organizations.
8. Financial statements showing the
				applicant's assets, liabilities, and sources of financial support. If the
				applicant's financial affairs are audited by an independent certified public
				accountant, a copy of the applicant's most recent regular certified financial
				statement is attached.
8.1 A copy of any contract made or to be made between the
				  applicant and its reinsurer
8.2A copy of any contract made or to be made between the
				  applicant and any person for cash or asset management services.
9. A description of the proposed
				method of marketing the plan, a financial plan which includes a three-year
				projection of operating results anticipated, and a statement as to the sources
				of funding.
10. A power of attorney
				executed by the applicant, if not domiciled in this state, appointing the
				commissioner, the commissioner's successors in office and deputies as the true
				and lawful attorney of the applicant for this state upon whom all lawful
				process in any legal action or proceeding against the LSO on a cause of action
				arising in this state may be served.
11. A statement reasonably describing the
				geographic area to be served and assessing in detail the economic feasibility
				of the LSO's projected operation.
12. A description of the complaint procedures
				to be utilized as required under Iowa Code section
				514B14..
13. A description of the procedures and
				programs to be implemented to meet the requirements for quality of health care
				as determined by the commissioner of insurance under Iowa Code section
				514B4..
14. A description of the mechanism by which
				enrollees shall be allowed to participate in matters of policy and operation as
				required by Iowa Code section
				514B7..
14.1 A copy of the notice to be given to enrollees of the
				  procedure for nomination and election of members of the governing body.
15. A schedule of the liability
				and workers' compensation insurance to be maintained in force by the LSO.
VERIFICATION
The undersigned deposes and states that deponent has duly
				  executed the attached application
dated_________________________,_____________, for and on
				  behalf of___________________; that
(Year) (Name of Applicant)
the deponent is the_______________________________of such
				  company, and that deponent is
(Title of Officer)
authorized to execute and file such instrument. Deponent
				  further states that deponent is familiar with such instrument and the contents
				  thereof, and that the facts therein set forth are true to the best of
				  deponent's knowledge, information and belief.
(Signature)
(type or print name beneath)
Subscribed and sworn to before me by________________on
				  this________day of__________________,
(Year)
(Notary Public)