Get Utilization Review Agent Application - Nebraska Department Of ...

This guide provides clear and comprehensive instructions for completing the Utilization Review Agent Application for the Nebraska Department of Insurance online. Follow these steps to ensure your application is filled out accurately and efficiently.

Follow the steps to complete the application successfully.

1. Click ‘Get Form’ button to access the application form and open it in your document management system.
2. Indicate the type of entity by checking the appropriate box: Corporation, Partnership, or Other. If you select ‘Other,’ please specify the type.
3. Fill in the name of the applicant in the designated field.
4. Provide the Federal I.D. number of the applicant.
5. Input the date of incorporation in the format of day, month, and year.
6. Enter the principal business address, including street address, city, state, and zip code.
7. Complete the telephone number field for the principal business address.
8. Provide the mailing address in the same manner as your principal business address, ensuring to include all required fields.
9. Specify the classes or types of insurance that the applicant will be conducting in Nebraska.
10. Attach the required documentation that shows the applicant has received approval or accreditation by the Utilization Review Accreditation Commission, Inc., or NCQUA.
11. Include a check for the application fee of $300 with your submission.
12. List the principal officers responsible for the operations, management, and control of the applicant. Provide their names, business addresses, residence addresses, social security numbers, and titles.
13. Ensure all named officers sign and date the application form.
14. Have the application notarized to complete the process.
15. Save your changes, then proceed to download, print, or share the completed application.

Complete your Utilization Review Agent Application online today to ensure a smooth application process.