191—40.11 (514B) Application for certificate of authority. The application for certificate of authority shall be in the following form:
HEALTH MAINTENANCE ORGANIZATION
APPLICATION FOR CERTIFICATE OF AUTHORITY
	
(Name of Health Maintenance Organization)
Organized as  	
under the laws of the state of ______________________________, hereby makes application to the commissioner of insurance for a certificate of authority to establish and operate a health maintenance organization in compliance with Iowa Code chapter 514B.
Attached hereto and hereby 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, partnership agreement, trust agreement, 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 health maintenance organization.
	      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 item (3).
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 health maintenance organization 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, his 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 health maintenance organization 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 HMO’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 in consideration, when deemed appropriate, with the director of public health, 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 workmen’s compensation insurance to be maintained in force by the health maintenance organization.
15.1 Copies of the forms of policies or contracts to be offered to terminated enrollees as provided in 40.10(2).
VERIFICATION
The undersigned deposes and says that deponent has duly executed the attached application dated ____________________, 20 ________, for and on behalf of  	 ;
(Name of Applicant)
that deponent is the  	  of such company,
(Title of Officer)
and that deponent is authorized to execute and file such instrument. Deponent further says 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 _________________________, 20 __________.
	
(Notary Public)