"Health Maintenance Organization Application for Certificate of Authority" - Kansas

Health Maintenance Organization Application for Certificate of Authority is a legal document that was released by the Kansas Insurance Department - a government authority operating within Kansas.

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INSURANCE DEPARTMENT
STATE OF KANSAS
HEALTH MAINTENANCE ORGANIZATION
APPLICATION FOR CERTIFICATE OF AUTHORITY
______________________, 20______
COMMISSIONER OF INSURANCE, Topeka, Kansas:
On behalf of __________________________________________________________________________
(Name of Health Maintenance Organization)
____________________________________________________________________________________,
(Registered Corporate Address in State of Domicile)
incorporated on ________________________.
(Date)
I (We) hereby apply for a CERTIFICATE OF AUTHORITY to transact business in the State of Kansas as
a Health Maintenance Organization.
Very truly yours,
_______________________________________
Corporate President Signature
_______________________________________
Printed Name
_______________________________________
Corporate Secretary Signature
_______________________________________
Printed Name
Business Mailing Address
and Telephone Number
_______________________________
_______________________________
_______________________________
_______________________________
INSURANCE DEPARTMENT
STATE OF KANSAS
HEALTH MAINTENANCE ORGANIZATION
APPLICATION FOR CERTIFICATE OF AUTHORITY
______________________, 20______
COMMISSIONER OF INSURANCE, Topeka, Kansas:
On behalf of __________________________________________________________________________
(Name of Health Maintenance Organization)
____________________________________________________________________________________,
(Registered Corporate Address in State of Domicile)
incorporated on ________________________.
(Date)
I (We) hereby apply for a CERTIFICATE OF AUTHORITY to transact business in the State of Kansas as
a Health Maintenance Organization.
Very truly yours,
_______________________________________
Corporate President Signature
_______________________________________
Printed Name
_______________________________________
Corporate Secretary Signature
_______________________________________
Printed Name
Business Mailing Address
and Telephone Number
_______________________________
_______________________________
_______________________________
_______________________________