Form DOI-IRO "Application for Certificate to Transact Business as an Independent Review Organization" - Nebraska

What Is Form DOI-IRO?

This is a legal form that was released by the Nebraska Department of Insurance - a government authority operating within Nebraska. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on October 1, 2015;
  • The latest edition provided by the Nebraska Department of Insurance;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form DOI-IRO by clicking the link below or browse more documents and templates provided by the Nebraska Department of Insurance.

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Download Form DOI-IRO "Application for Certificate to Transact Business as an Independent Review Organization" - Nebraska

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NEBRASKA DEPARTMENT OF INSURANCE
APPLICATION FOR CERTIFICATE TO TRANSACT BUSINESS
AS AN INDEPENDENT REVIEW ORGANIZATION
Pursuant to Neb.Rev.Stat. §44-1312
Name of Applicant: ________________________________________________________________________
Federal I.D. # ______________________________
Date Incorporated ____________________________
Principal Business Address: _________________________________________________________________
Street Address
______________________________
__________
____________________
______________________
City
State
Zip Code
Phone
Mailing Address: ___________________________________________________________________________
Street Address
______________________________
__________
____________________
______________________
City
State
Zip Code
Phone
Submitter’s Name: _____________________________
Email Address: ___________________________
Please submit with the application, documentation that the applicant has received approval or accreditation by
the a nationally recognized private accrediting entity.
Please also include a check in the amount of $100.00 in payment of the application fee.
NEBRASKA DEPARTMENT OF INSURANCE
INSURANCE LICENSING DIVISION
P.O. BOX 82089
LINCOLN, NE 68501-2089
E-mail: DOI.Licensing@Nebraska.gov
Licensing Division: (402) 471-4913
DOI Main Line: (402) 471-2201
Fax: (402) 471-6559
DOI-IRO
Page 1 of 2
Rev. 10/15
NEBRASKA DEPARTMENT OF INSURANCE
APPLICATION FOR CERTIFICATE TO TRANSACT BUSINESS
AS AN INDEPENDENT REVIEW ORGANIZATION
Pursuant to Neb.Rev.Stat. §44-1312
Name of Applicant: ________________________________________________________________________
Federal I.D. # ______________________________
Date Incorporated ____________________________
Principal Business Address: _________________________________________________________________
Street Address
______________________________
__________
____________________
______________________
City
State
Zip Code
Phone
Mailing Address: ___________________________________________________________________________
Street Address
______________________________
__________
____________________
______________________
City
State
Zip Code
Phone
Submitter’s Name: _____________________________
Email Address: ___________________________
Please submit with the application, documentation that the applicant has received approval or accreditation by
the a nationally recognized private accrediting entity.
Please also include a check in the amount of $100.00 in payment of the application fee.
NEBRASKA DEPARTMENT OF INSURANCE
INSURANCE LICENSING DIVISION
P.O. BOX 82089
LINCOLN, NE 68501-2089
E-mail: DOI.Licensing@Nebraska.gov
Licensing Division: (402) 471-4913
DOI Main Line: (402) 471-2201
Fax: (402) 471-6559
DOI-IRO
Page 1 of 2
Rev. 10/15
List below the principal officers responsible for the operations, management and control of
the applicant name herein:
Officer 1
Name:
Title:
Business Address:
Resident Address:
Social Security Number:
Officer 2
Name:
Title:
Business Address:
Resident Address:
Social Security Number:
Officer 3
Name:
Title:
Business Address:
Resident Address:
Social Security Number:
Officer 4
Name:
Title:
Business Address:
Resident Address:
Social Security Number:
This application must be signed by all named principle officers listed above.
Officer 1: ________________________________________________
____________________
Signature
Date
Officer 2: ________________________________________________
____________________
Signature
Date
Officer 3: ________________________________________________
____________________
Signature
Date
Officer 4: ________________________________________________
____________________
Signature
Date
Article 13 – Health Carrier External Review Act:
http://nebraskalegislature.gov/laws/statutes.php?statute=44-1301
DOI-IRO
Page 2 of 2
Rev. 10/15
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