FIN302 | 1116
APPLICATION FOR CERTIFICATE OF AUTHORITY
TO DO BUSINESS IN THE STATE OF TEXAS
Employers ID No. _________________________
____________________________________________________________________
(Mailing Address)
____________________________________________________________________
(City)
(State)
(Zip Code)
____________________
___________________
___________________
(Office Phone)
(Fax Number)
(Toll Free Number)
____________________________________________________________________
(Location of Books & Records—Domestic Only)
____________________________________________________________________
(Month)
(Day)
(Year)
TO THE COMMISSIONER OF INSURANCE OF THE STATE OF TEXAS:
On behalf of _____________________________________________________________________________________________________
(Give name of Health Maintenance Organization in full)
whose home office is located at ______________________________________________________________________________________
(Street Address of Incorporation)
in ____________________________________________, ________________________________________________________________
(City of Incorporation)
(State of Incorporation)
(Zip Code)
we hereby apply for a certificate of authority authorizing said Health Maintenance Organization to be licensed as a
Health Maintenance Organization in the State of Texas in compliance with the Texas HMO Act and the Rules and
Regulations for Health Maintenance Organizations.
TYPE OF OWNERSHIP (Legal Entity)
Individual
( )
Association
( )
Profit
( )
Partnership
( )
Cooperative
( )
Non-Profit
( )
Corporation
( )
Other ___________________________________________________
We hereby certify that to the best of our knowledge and belief, the application of Certificate of Authority presented consists
of all required by the Rules and Regulations governing Health Maintenance Organizations and is true, accurate and complete.
______________________________________________
Name
______________________________________________
Title
(Corporate Seal)
______________________________________________
Name
______________________________________________
Title
Texas Department of Insurance | www.tdi.texas.gov
1/1
FIN302 | 1116
APPLICATION FOR CERTIFICATE OF AUTHORITY
TO DO BUSINESS IN THE STATE OF TEXAS
Employers ID No. _________________________
____________________________________________________________________
(Mailing Address)
____________________________________________________________________
(City)
(State)
(Zip Code)
____________________
___________________
___________________
(Office Phone)
(Fax Number)
(Toll Free Number)
____________________________________________________________________
(Location of Books & Records—Domestic Only)
____________________________________________________________________
(Month)
(Day)
(Year)
TO THE COMMISSIONER OF INSURANCE OF THE STATE OF TEXAS:
On behalf of _____________________________________________________________________________________________________
(Give name of Health Maintenance Organization in full)
whose home office is located at ______________________________________________________________________________________
(Street Address of Incorporation)
in ____________________________________________, ________________________________________________________________
(City of Incorporation)
(State of Incorporation)
(Zip Code)
we hereby apply for a certificate of authority authorizing said Health Maintenance Organization to be licensed as a
Health Maintenance Organization in the State of Texas in compliance with the Texas HMO Act and the Rules and
Regulations for Health Maintenance Organizations.
TYPE OF OWNERSHIP (Legal Entity)
Individual
( )
Association
( )
Profit
( )
Partnership
( )
Cooperative
( )
Non-Profit
( )
Corporation
( )
Other ___________________________________________________
We hereby certify that to the best of our knowledge and belief, the application of Certificate of Authority presented consists
of all required by the Rules and Regulations governing Health Maintenance Organizations and is true, accurate and complete.
______________________________________________
Name
______________________________________________
Title
(Corporate Seal)
______________________________________________
Name
______________________________________________
Title
Texas Department of Insurance | www.tdi.texas.gov
1/1
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