Get Application For Certificate Of Authority ... - Minnesota.gov - Mn

This guide provides clear instructions on how to complete the Application for Certificate of Authority for Prepaid Limited Health Service Organization domiciled in Minnesota. Whether you are a novice or have some experience in filling out forms, this guide will assist you step-by-step.

Follow the steps to successfully complete the application.

1. Press the ‘Get Form’ button to access the application and open it in the editor.
2. Enter the entity name in the designated field. Ensure that this matches the name as registered.
3. Fill in the entity address, including street, city, state, and zip code.
4. Provide the general phone number, fax number, and email address for contact.
5. Designate a contact person by filling in their name and phone number.
6. Gather and upload necessary documents as required, such as the certified copy of organizational documents, financial statement, and bylaws. Follow the specific requirements in the itemized list.
7. Complete the ownership structure by denoting the percentages in the organizational chart as required.
8. Execute and upload the biographical affidavits using the provided NAIC form for all listed individuals responsible for the entity.
9. Provide detailed financial information including assets, liabilities, and other fiscal statements, ensuring to meet the tangible net equity requirements.
10. Review the acknowledgment for service of process and ensure it is signed by the appropriate individuals, including the president and secretary.
11. Finalize the application by checking all fields for accuracy. Once satisfied, save your changes, download, print, or share the application as needed.

Take action today by completing your document online!