Form H-1 Application for Managed Care Organization Certificate of Authority - Delaware

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APPLICATION FOR
MANAGED CARE ORGANIZATION
CERTIFICATE OF AUTHORITY
APPLICATION IS HEREBY MADE BY:
CORPORATE TITLE
CORPORATE ADDRESS
ADMINISTRATIVE/MAILING ADDRESS
INCORPORATED OR ORGANIZED ON ________________________________, IN ______________________
AS A __________________________________ (STOCK, MUTUAL, RECIPROCAL, FRATERNAL, MUTUAL
BENEFIT, ETC.) INSURER FOR A CERTIFICATE OF AUTHORITY TO TRANSACT THE BUSINESS OF
INSURANCE WITHIN THE STATE OF DELAWARE FOR THE LINE OF ACCIDENT AND HEALTH, AS SET
FORTH IN TITLE 18, DELAWARE CODE.
FEDERAL EMPLOYER’S IDENTIFICATION NUMBER (EIN) ____________________________
______________________________________________
CORPORATE TITLE
BY: ___________________________________
TITLE: ________________________________
DATE: ________________________________
Form No. H-1
Print Form
APPLICATION FOR
MANAGED CARE ORGANIZATION
CERTIFICATE OF AUTHORITY
APPLICATION IS HEREBY MADE BY:
CORPORATE TITLE
CORPORATE ADDRESS
ADMINISTRATIVE/MAILING ADDRESS
INCORPORATED OR ORGANIZED ON ________________________________, IN ______________________
AS A __________________________________ (STOCK, MUTUAL, RECIPROCAL, FRATERNAL, MUTUAL
BENEFIT, ETC.) INSURER FOR A CERTIFICATE OF AUTHORITY TO TRANSACT THE BUSINESS OF
INSURANCE WITHIN THE STATE OF DELAWARE FOR THE LINE OF ACCIDENT AND HEALTH, AS SET
FORTH IN TITLE 18, DELAWARE CODE.
FEDERAL EMPLOYER’S IDENTIFICATION NUMBER (EIN) ____________________________
______________________________________________
CORPORATE TITLE
BY: ___________________________________
TITLE: ________________________________
DATE: ________________________________
Form No. H-1
Print Form

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