Fillable 2019-Application For Registration As A Purchasing Group With Apointment Of Attorney (Commonwealth of Massachusetts)

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2019-Application For Registration As A Purchasing Group With Apointment Of Attorney (Commonwealth of Massachusetts)

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BROWSE COMMONWEALTH OF MASSACHUSETTS (MA) FORMS

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Revised 7/1/19
Commonwealth of Massachusetts
NEW / ANNUAL / AMENDED ANNUAL
APPLICATION FOR REGISTRATION AS A PURCHASING GROUP
Date:
This is a new application, ending June 30 of the current/following year.
This is an annual application for the year beginning July 1,
and ending June 30 of the
following year.
This is an amended annual application.
If amending, check and fill out only the name of the group and applicable sections. There is no fee for an
amended application.
Please note that a non-refundable filing fee of $125, payable to the Commonwealth of Massachusetts,
must accompany every annual application. Mail with completed application to the Division of Insurance,
1000 Washington Street, Suite 810, Boston, MA 02118-6200
If this is the group’s initial application, it must attach a certificate appointing the Commissioner of
Insurance as its attorney to receive service of legal process issued against it in the commonwealth. The
appointment must be irrevocable, shall bind any successor in interest, and shall remain in effect as long
as there remain any obligations or liabilities of the group.
1. List the exact name of the Purchasing Group.
2. Indicate the form of organization or incorporation.
3. The Purchasing Group is domiciled in the State of:
4. List any other names under which the Purchasing Group is or may be doing business in this state
or any other state if different than above.
5. List the complete physical address of the Purchasing Group.
6.
List the name, address, telephone number and email of the principal staff person or officer of
the Purchasing Group who has knowledge of its insurance program, including membership
criteria, coverages, and key personnel of the group’s administrator and insurance carrier
Address 1
Address 2
City /State /Zip
Name
Address 1
Address 2
City /State /Zip
Telephone / Email
Alabama
AK
AK
ANNUAL APPLICATION FOR REGISTRATION AS A PURCHASING GROUP Page 2
Revised 7/1/19
List the name, address and telephone number of the principal agent or broker responsible for
the
sale or
pu
rchase of the group’s liability insurance. (If none, answer
"none".)
7.
6A.
List the name, address, telephone number, and email of the firm that acts as the
administrator of the Purchasing Group, and the name of the principal account executive
responsible for the group's insurance program. (If none, answer "none".)
6B.
Name
Address 1
Address 2
City / State / Zip
Name
Address 1
Address 2
City / State / Zip
List the names, addresses, and occupations of the principal officers and directors of the
Purchasing Group. Attach additional pages if necessary.
Principal Officers
Telephone / Email
Name
Address 1
Address 2
City / State / Zip
Occupation
Name
Address 1
Address 2
City / State / Zip
Occupation
Directors
Name
Address 1
Address 2
City / State / Zip
Occupation
Name
Address 1
Address 2
City /State / Zip
Occupation
Telephone / Email
AK
AK
AK
AK
AK
AK
8.
The Purchasing group is composed of members whose business 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
the business or activities engaged in by purchasing group members.
ANNUAL APPLICATION FOR REGISTRATION AS A PURCHASING GROUP
Page 3
9.
The Purchasing Group has as one of its purposes the purchase of liability insurance on a group basis.
True
False
10.
The Purchasing group purchases such liability insurance only for its members and only to cover
their similar or related liability esposure as described in item 8 above.
True
False
11.
The Purchasing Group currently purchases and intends to purchase the following lines and
classifications of liability insurance.
Lines
Classifications
Revised 7/1/19
12.
The Purchasing Group currently purchases and intends to purchase the liability insurance described
in item 11 above from the following insuranvce company or companies. Give the full name of the
company, its state of domicile, and FEIN.
Name of Company
State of
NAIC #
Domicile
AK
AK
AK
AK
AK
ANNUAL APPLICATION FOR REGISTRATION AS A PURCHASING GROUP Page 4
Revised 7/1/19
13.
List the name and address of the licensed agent or broker through whom current purchases have
been made and future purchases will be made. Complete this item only if the purchase of
insurance is or will be made from a surplus lines insurer, rather than from a licensed insurer.
Name
Address 1
Address 2
City / State / Zip
14.
If the Purchasing Group transacts insurance business by means of a "direct offering" (without using
insurance agents to market the program), list the name and address of each person not listed in item
13 above who will be transacting business on behalf of the group. (You need not include the names
of licensed insurance agents duly appointed by an admitted insurer.)
Name
Address1
Address2
City / State / Zip
Name
Address1
Address2
City / State / Zip
15.
States where the Purchasing Group does, or intends to do business:
The group eventually intends to do business in all states (including the District of Columbia).
The group eventually intends to do business in all states (including the District of Columbia)
except for the following states.
The group eventually intends to do business only in the following states:
Name
Address1
Address2
City / State / Zip
Telephone / Email
AK
AK
AK
AK
AK
MA
MA
MA
MA
MA
MA
MA
MA
MA
ANNUAL APPLICATION FOR REGISTRATION AS A PURCHASING GROUP
Page 5
Revised 7/1/19
16.
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 c
harge currently pending against such person?
(B) Had denied any application for a professional,
vocational or business lic
ense
(C) Had withdrawn or surrendered any such application or
license to avoid disciplinary action against the licensee
Yes No
If the answer to any part of this question is “yes”, attach a supplementary statement explaining
in full each occurrence.
We do hereby swear and affirm that the aforementioned statements and information are true and
correct.
_____________________________
President or Chief Executive Officer
_____________________________
Secretary
Sworn before me this
_______ Day of
__________________________________________
Notary Public, State of
My commission expires:
Y
es
No
Yes No
ANNUAL APPLICATION FOR REGISTRATION AS A PURCHASING GROUP Page 6
Revised 7/1/19
COMMONWEALTH OF MASSACHUSETTS
APPOINTMENT OF ATTORNEY TO ACCEPT SERVICE
The ,a Purchasing
Group (called the Group) duly organized under the laws of the State of
hereby appoints the Commissioner of Insurance of the Commonwealth of Massachusetts (the
Commissioner), and his or her successors in office, to be its lawful attorney, upon whom all legal
processes in any legal action or proceeding against it shall be served, and further agrees that any lawful
process against it which is served on the Commissioner shall have the same legal validity as if served
personally on the Group
The Group gives the Commissioner, and his or her successors, full authority to do every act
necessary to be done under this appointment as fully as the group could do it if personally present, and
ratifies all acts the Commissioner shall lawfully do under the power granted by this appointment. This
authority may be withdrawn only upon a written notice of revocation to the Commissioner, and, in any
case, shall continue in effect so long as any liability arising out of this appointment remains outstanding in
the Commonwealth. This instrument is executed pursuant to and shall be construed to constitute full
compliance with M.G.L. c. 176L, §7 ¶C of the Massachusetts Liability Risk Retention Act and with 15 USC
3903 §4 (e) of the Federal Liability Risk Retention Act.
The group designates
whose address is
as the person to whom p
rocess against the Group served on the Commissioner shall be forwarded.
In Witness of this appointment, the Group, pursuant to a resolution duly adopted by its Board of
Directors has caused this instrument to be executed in its name by its President, and Secretary, and
its corporate seal affixed, at the city of _____________________, State of
Attest:
_____________________________
Secretary
_____________________________
Name of Purchasing Group
By
_____________________________
Sworn before me this ____ Day of _____________
Notary Public, State of _______________________
My commission expires ______________________
this __________ day
of _____________________ 20 ______.
President
Alabama
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2019-Application For Registration As A Purchasing Group With Apointment Of Attorney (Commonwealth of Massachusetts)

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Completed 28 July 2020

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