"Purchasing Group Notice and Registration Form" - Mississippi

Purchasing Group Notice and Registration Form is a legal document that was released by the Mississippi Department of Insurance - a government authority operating within Mississippi.

Form Details:

  • Released on February 1, 2008;
  • The latest edition currently provided by the Mississippi Department of Insurance;
  • Ready to use and print;
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  • Fill out the form in our online filing application.

Download a fillable version of the form by clicking the link below or browse more documents and templates provided by the Mississippi Department of Insurance.

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MAILING ADDRESS:
MIKE CHANEY
Commissioner of Insurance
P.O. Box 79
State Fire Marshal
Jackson, MS. 39205-0079
Phone: 601-359-3569
Fax: 601-359-2474
MARK HAIRE
Deputy Commissioner of Insurance
MISSISSIPPI INSURANCE DEPARTMENT
501 N. WEST STREET, SUITE 1001
WOOLFOLK BUILDING
JACKSON, MISSISSIPPI 39201
www.mid.ms.gov
PURCHASING GROUP REGISTRATION CHECKLIST
Please provide the first five items with your initial application:
1.
Completed (NAIC) Purchasing Group registration form.
2.
Completed service of process form.
3.
Copies of all rates, rules and forms to be used in Mississippi must be filed for informational purposes only.
Rates, rules and forms should be filed and approved in the Purchasing Group’s domiciliary insurance department,
no filing fee required. If the Purchasing Group uses only surplus lines insurers, you may submit a letter from the
group’s domiciliary insurance department stating that no rates, rules and forms have been filed with them because
the group is not using admitted companies.
4.
Copy of letter of approval from Purchasing Group’s domiciliary insurance department showing that the group is
eligible to do business in that state.
Additional information:
1.
Complete and return premium tax form and taxes quarterly.
2.
Annual report listing premiums written on Mississippi risks which are due March 1.
3.
Complete and return renewal form by March 1.
See Miss. Code Ann. § 83-55-1 et seq. for the Mississippi Risk Retention Act.
Rev. 02/08
 
  
MAILING ADDRESS:
MIKE CHANEY
Commissioner of Insurance
P.O. Box 79
State Fire Marshal
Jackson, MS. 39205-0079
Phone: 601-359-3569
Fax: 601-359-2474
MARK HAIRE
Deputy Commissioner of Insurance
MISSISSIPPI INSURANCE DEPARTMENT
501 N. WEST STREET, SUITE 1001
WOOLFOLK BUILDING
JACKSON, MISSISSIPPI 39201
www.mid.ms.gov
PURCHASING GROUP REGISTRATION CHECKLIST
Please provide the first five items with your initial application:
1.
Completed (NAIC) Purchasing Group registration form.
2.
Completed service of process form.
3.
Copies of all rates, rules and forms to be used in Mississippi must be filed for informational purposes only.
Rates, rules and forms should be filed and approved in the Purchasing Group’s domiciliary insurance department,
no filing fee required. If the Purchasing Group uses only surplus lines insurers, you may submit a letter from the
group’s domiciliary insurance department stating that no rates, rules and forms have been filed with them because
the group is not using admitted companies.
4.
Copy of letter of approval from Purchasing Group’s domiciliary insurance department showing that the group is
eligible to do business in that state.
Additional information:
1.
Complete and return premium tax form and taxes quarterly.
2.
Annual report listing premiums written on Mississippi risks which are due March 1.
3.
Complete and return renewal form by March 1.
See Miss. Code Ann. § 83-55-1 et seq. for the Mississippi Risk Retention Act.
Rev. 02/08
 
Part A
STATE OF MISSISSIPPI
DEPARTMENT OF INSURANCE
PURCHASING GROUP - NOTICE AND REGISTRATION
(All Information Should Be Typed)
1.
Name of the Purchasing Group:
_____________________________________________________________________________________________
2.
List any other name(s) by which the Purchasing Group is known or may be doing business in this State or any other state:
______________________________________________________________________________________________
______________________________________________________________________________________________
3.
a)
Form of organization (i.e., corporation, partnership, association) and the state in which
organized:
______________________________________________________________________________________________
b)
Purpose(s) of organization:
______________________________________________________________________________________________
______________________________________________________________________________________________
4.
a)
The Purchasing Group is domiciled in the state of: _______________________________________________
b)
Address: _______________________________________________________________________________
_______________________________________________________________________________
5.
Physical address of the administrative offices of the Purchasing Group, if different from response to Item #4b above:
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
6.
The Purchasing Group intends to purchase the following classifications of liability insurance and/or sub classifications
thereof:
_______________________________________________________________________________________________
_______________________________________________________________________________________________
 
PURCHASING GROUP FORM
7.
The Purchasing Group intends to purchase the liability insurance described in Item #6 above from the following insurance
company or companies; [Give full name of company, state of domicile, NAIC code and Federal Employer Identification
Number (FEIN)].
State of
Name of Company
Domicile
NAIC Code
FEIN
__________________ ___________________ ___________________ _____________________
__________________ ___________________ ___________________ _____________________
__________________ ___________________ ___________________ _____________________
8.
List the name, address and social security number (SS#) of each officer and director of the Purchasing Group: (Attach
additional pages if necessary.)
Position with
Name
Address
SS#
Purchasing Group
___________ ____________________ ________________ ______________________________
___________ ____________________ ________________ ______________________________
___________ ____________________ ________________ ______________________________
___________ ____________________ ________________ ______________________________
9.
List the name, SS#, address and telephone number of the person within the Purchasing Group who is most knowledgeable
about the Purchasing Group’s insurance program, including membership criteria and coverages:
Name
SS#
Address
Telephone #
______________ ________________ ________________ _______________________________
______________ ________________ ________________ _______________________________
10.
List the name, FEIN, address and telephone number of the company that manages or administers the insurance program for
the Purchasing Group, and the name, SS# and telephone number of the person responsible for the Group’s insurance
program: (If none, answer none.)
Name
FEIN/SS#
Address
Telephone #
______________ ________________ ________________ _______________________________
______________ ________________ ________________ _______________________________
______________ ________________ ________________ _______________________________
 
PURCHASING GROUP FORM
11.
List the name(s), SS#(s) and address(es) of the licensed insurance agent(s), broker(s) or excess (surplus) lines
broker(s) responsible for the purchase of liability insurance for the Purchasing Group and its members and the
state(s) in which they are licensed: (Attach additional pages, if necessary. If none, answer none.)
Name
SS#
Address
State(s)
______________ ________________ ___________________ ___________________________
______________ ________________ ___________________ ___________________________
______________ ________________ ___________________ ___________________________
12.
Has any person transacting business on behalf of this Purchasing Group ever:
a) been arrested, indicted and convicted of a felony or is a felony charge currently pending against any such
person? _______________
b) had denied any application for a professional, vocational or business license: ______________
c) had suspended or revoked any such license? __________________
d) had withdrawn or surrendered any such application or license to avoid potential disciplinary action against
licensee? ______________________
If the answer to any part of this question is yes, attach a supplementary statement explaining in full each such
occurrence.
13.
The Purchasing Group is composed of members whose businesses or activities are similar or related with
respect to the liability to which members are exposed by virtue of any related, similar or common business,
trade, product, services, premises or operations. Give a general description of business or activities engaged in
by Purchasing Group members:
_________________________________________________________________________________________
__________________________________________________________
_________
____________________________________________________________________________
__
14.
The Purchasing Group purchases the liability insurance listed in Item #6 above only for its group members and
only to cover their similar or related liability exposure, as described in Item #13 above.
15.
The Purchasing Group has as one of its purposes the purchase of liability insurance on a group basis.
 
Part B
PURCHASING GROUP FORM
APPOINTMENT OF ATTORNEY TO ACCEPT SERVICE AND DESIGNATION
The ______________________________________________(“the Group”), a purchasing group organized under the
laws of the State of ______________________, having notified the Insurance Commissioner (Director, Superintendent)
of the State of _________________ of its intention to do business in this State as a purchasing group pursuant to the
federal Liability Risk Retention Act of l986, hereby appoints the Insurance Commissioner [Director, Superintendent] of
the State of _________________, any successor in office, and any authorized deputy its true and lawful attorney, in and
for the State of _________________, upon whom all legal documents or process in any proceeding against it may be
served. Such service of process shall be of the same legal force and validity as if served personally upon the Group.
The Group designates:
______________________________
(Name)
______________________________
(Address)
______________________________
(City, Town or Village)
______________________________
(State and ZIP Code)
as its officer, agent or other person to whom shall be forwarded all legal documents or process served upon the
Insurance Commissioner [Director, Superintendent] of the State of ______________________, any successors in
office, or any authorized deputy, for the Group. This designation shall continue in full force and effect until superseded
by a new written designation filed with the Insurance Commissioner [Director, Superintendent].
 
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