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What is the MEWA s fund balance Comments Signature of Chair of Board Form M400 Date Printed Name of Signature Title Ver. RENEWAL APPLICATION FOR REGISTRATION OF MULTIPLE EMPLOYER WELFARE ARRANGEMENT MEWA -IC 27-1-34-1 NOTE Multiple Employer Welfare Arrangement means an entity other than a duly admitted insurer that establishes an employee benefit plan for the purpose of offering or providing accident and sickness or death benefits to the employees of at least two 2 employers including self-employed individuals and their dependents. 1. Applicants Certification A. I certify that there have been no changes to the application information and documentation submitted during the last year attached the revised documentation* 2. Full name of MEWA 3. Statutory home address of MEWA street city state ZIP code 4. Mailing address of MEWA street city state ZIP code 5. Contact person of MEWA 5a* Title 5b. Telephone number 6. Are the employers in the MEWA members of an association or group of two 2 or more businesses in the same trade or industry yes no 6a* List trade or industry 7. Is the association substantially involved in the activity for its members other than sponsorship If answer is no please explain 8. Has the MEWA s fiscal year changed 9. Is the MEWA a non-for-profit organization 10. Does the MEWA have a contract with a third party administrator yes 10a* If answer is yes list or attached the name of the third party 11. Are any of the trustees an owner officer or employee if the administrator If yes please explain 12. RENEWAL APPLICATION FOR REGISTRATION OF MULTIPLE EMPLOYER WELFARE ARRANGEMENT MEWA -IC 27-1-34-1 NOTE Multiple Employer Welfare Arrangement means an entity other than a duly admitted insurer that establishes an employee benefit plan for the purpose of offering or providing accident and sickness or death benefits to the employees of at least two 2 employers including self-employed individuals and their dependents. 1. Applicants Certification A. I certify that there have been no changes to the application information and documentation submitted during the last year attached the revised documentation* 2. 1. Applicants Certification A. I certify that there have been no changes to the application information and documentation submitted during the last year attached the revised documentation* 2. Full name of MEWA 3. Statutory home address of MEWA street city state ZIP code 4. Mailing address of MEWA street city state ZIP code 5. Full name of MEWA 3. Statutory home address of MEWA street city state ZIP code 4. Mailing address of MEWA street city state ZIP code 5. Contact person of MEWA 5a* Title 5b. Telephone number 6. Are the employers in the MEWA members of an association or group of two 2 or more businesses in the same trade or industry yes no 6a* List trade or industry 7. Contact person of MEWA 5a* Title 5b. Telephone number 6. Are the employers in the MEWA members of an association or group of two 2 or more businesses in the same trade or industry yes no 6a* List trade or industry 7. Is the association substantially involved in the activity for its members other than sponsorship If answer is no please explain 8.