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
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.
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.
