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)
