"Performance Bond for Medicaid Hics" - Ohio

Performance Bond for Medicaid Hics is a legal document that was released by the Ohio Department of Insurance - a government authority operating within Ohio.

Form Details:

  • Released on April 1, 2006;
  • The latest edition currently provided by the Ohio Department of Insurance;
  • Ready to use and print;
  • Easy to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of the form by clicking the link below or browse more documents and templates provided by the Ohio Department of Insurance.

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PERFORMANCE BOND
[Insurance Company’s Name And Address]
Know all men by these presents, that we
[Health Insuring Corporation’s Name And Address]
, as Principal, (hereinafter called “Principal”) and
_________________________________________________________________________, a(n)
[Insurance Company’s Name]
_____________________________ corporation, as Surety (hereinafter called “Surety”), are held
[State]
and firmly bound unto the State of Ohio, as Obligee, in the just and full sum of three million
U.S. dollars ($3,000,000) for the payment of which we bind ourselves, our heirs, executors,
administrators, successors and assigns, jointly and severally.
WHEREAS, the Principal pursuant to Revised Code Section 5111.17 has or is about to enter
into a written Agreement with the State of Ohio through one of its Departments to provide or
arrange for the provision of health care services to Medicaid recipients under a health insuring
corporation Certificate of Authority issued or to be issued by the Ohio Department of
Insurance.
WHEREAS, pursuant to Revised Code Section 1751.271, the Principal is required to post a
performance bond as security to fulfill the obligations of a health insuring corporation to pay
claims of contracted providers for covered health care services provided to Medicaid
recipients.
Revised 04-2006
This policy form is acceptable to the Ohio Department of Insurance in order to comply
with Ohio Revised Code 1751.271
PERFORMANCE BOND
[Insurance Company’s Name And Address]
Know all men by these presents, that we
[Health Insuring Corporation’s Name And Address]
, as Principal, (hereinafter called “Principal”) and
_________________________________________________________________________, a(n)
[Insurance Company’s Name]
_____________________________ corporation, as Surety (hereinafter called “Surety”), are held
[State]
and firmly bound unto the State of Ohio, as Obligee, in the just and full sum of three million
U.S. dollars ($3,000,000) for the payment of which we bind ourselves, our heirs, executors,
administrators, successors and assigns, jointly and severally.
WHEREAS, the Principal pursuant to Revised Code Section 5111.17 has or is about to enter
into a written Agreement with the State of Ohio through one of its Departments to provide or
arrange for the provision of health care services to Medicaid recipients under a health insuring
corporation Certificate of Authority issued or to be issued by the Ohio Department of
Insurance.
WHEREAS, pursuant to Revised Code Section 1751.271, the Principal is required to post a
performance bond as security to fulfill the obligations of a health insuring corporation to pay
claims of contracted providers for covered health care services provided to Medicaid
recipients.
Revised 04-2006
This policy form is acceptable to the Ohio Department of Insurance in order to comply
with Ohio Revised Code 1751.271
NOW, THEREFORE, THE CONDITION OF THIS OBLIGATION IS SUCH, that if the
Principal shall well and truly pay claims of contracted providers for covered health care
services provided to Medicaid recipients, then this obligation shall be void; otherwise to
remain in full force and effect.
FURTHERMORE, it is understood that:
1. In the event the Principal is placed in rehabilitation or liquidation under Chapter 3903 of the
Revised Code, this bond shall be payable to Obligee in full and shall become a special deposit
subject to Section 3903.14 or Section 3903.421 of the Revised Code.
2. The Principal or Surety may cancel this bond by giving ninety (90) days written notice to the
Obligee. If this bond is canceled, the Surety shall have no liability arising out of payment
obligations accruing after the effective date of the cancellation, but shall remain liable for
obligations that accrued prior to that date.
3. The aggregate liability of the Surety shall not exceed the penal amount of this bond
regardless of the number of years this bond remains in force, the number of premiums paid
or the number of claims made by the Obligee.
Signed this
day of
, 20
.
(Principal)
[Insurance Company’s Name and Address]
By: __________________________________
____________________________________
Title: _________________________________
____________________________________
____________________________________
By: __________________________________
Title: _________________________________
Revised 04-2006
This policy form is acceptable to the Ohio Department of Insurance in order to comply
with Ohio Revised Code 1751.271
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