"Purchasing Group Notice and Registration Form" - Ohio

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

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INSURANCE DEPARTMENT
PURCHASING GROUP NOTICE AND REGISTRATION
(All Information Should Be Typed)
1. List the exact 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) Indicate the form of the 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. List the physical address of the administrative offices of the Purchasing Group, if different from
response to Item #4b above:
INSURANCE DEPARTMENT
PURCHASING GROUP NOTICE AND REGISTRATION
(All Information Should Be Typed)
1. List the exact 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) Indicate the form of the 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. List the 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 lines and classifications of liability
insurance:
7. The Purchasing Group intends to purchase the liability insurance described in Item #6 above from
the following company or companies: Give full name of company, state of domicile, and Federal
Employer Identification Number (FEIN).
Name of Company
State of Domicile
FEIN
8. List the name, address and social security number (SS#) of each officer and director of the
Purchasing Group: (Attach additional pages is 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, address and telephone number of the company that manages or administers the
insurance program for the Purchasing Group, and the name and telephone number of the person
responsible for the Group’s insurance program: (If none, answer none.)
Name
Address
Telephone#
11. List the name(s), SS#(s) and address(es) of the licensed agent(s), broker(s) or excess (surplus)
line broker(s) responsible for the purchase of liability insurance for the Purchasing Group
members: (Attach additional pages, if necessary.)
Name
SS#
Address
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 #8 above only for its group
members and only to cover their similar or related liability exposure, as described in Item #14
above.
15. The Purchasing Group has as one of its purposes the purchase of liability insurance on a group
basis.
16. The Purchasing Group has designated the Insurance Commissioner of this State to be its agent
solely for the purpose for receiving service of legal documents or process by executing Part B of
this form, attached hereto.
17. The Purchasing Group has submitted a non-refundable registration fee of $_____ payable to the
Insurance Commissioner of this State.
18. The Purchasing Group will not purchase any insurance policy in this state which provides coverage
prohibited generally by statute of this state or declared unlawful by the highest court of this state
whose law applies to such policy.
19. The Purchasing Group will comply with all other applicable state laws.
20. The Purchasing Group will notify the Insurance Commissioner( D irector, Superintendent)
of any subsequent changes in any of the items included in this form.
The undersigned hereby swear and affirm that the foregoing statements and information
regarding their principal, the
Name of Purchasing Group)
(
are true and correct.
President of the Purchasing Group
Secretary of the Purchasing Group
State of
}
ss:
County of
Sworn before me this
day of ______________________, 20 _____.
Notary Public.
_____________________________________________________,
My Commission Expires: ___________________________
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 1986, hereby appoints the Insurance Commissioner (Director, Superintendent) of the State of _________,
any sucessor in office, and any authorized deputy for its true and lawful attorney, in and for the State of ________,
upon whom 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 sucessors 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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