191—41.10 (514B) Application for certificate of authority. 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.
4.2 A 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.
8.2 A 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 514B.14.
	  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 514B.4.
	  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 514B.7.
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)