Fillable APPLICATION FOR MANAGED CARE ORGANIZATION CERTIFICATE OF AUTHORITY (Department of Technology and Information)

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APPLICATION FOR MANAGED CARE ORGANIZATION CERTIFICATE OF AUTHORITY (Department of Technology and Information)

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U.S.A. forms for Department of Technology and Information

BROWSE DEPARTMENT OF TECHNOLOGY AND INFORMATION (DE) FORMS

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1351 West North Street, Suite 101, Dover, DE 19904 •
insurance.delaware.gov
(302) 674-7300 Dover • (302) 739-5280 fax • (302) 577-5280 Wilmington
Office of the
Commissioner
State of Delaware
Department of Insurance
APPLICATION FOR MANAGED CARE ORGANIZATION
CERTIFICATE OF AUTHORITY – H-1 FORM
Application is hereby made by:
Corporate Title
Corporate Address
Administrative/Mailing Address
Incorporated or Organized on , in as a
stock 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 1, Delaware Code.
Federal Employer’s Identification Number (FEIN)
By:
Title:
Date:
Corporate Title
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APPLICATION FOR MANAGED CARE ORGANIZATION CERTIFICATE OF AUTHORITY (Department of Technology and Information)

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Completed 13 August 2020

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