Fillable Multiple Employer Welfare Arrangements (MEWA) Annual Filing for (Department of Technology and Information)

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Multiple Employer Welfare Arrangements (MEWA) Annual Filing for (Department of Technology and Information)

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BROWSE DEPARTMENT OF TECHNOLOGY AND INFORMATION (DE) FORMS

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Annual Renewal | 1
Multiple Employer Welfare Arrangements (MEWA)
Annual Filing for Licensure and Annual Filing Update
Only use this form for an annual filing and for an update to the annual filing made pursuant to 18 DE Admin. Code §
1405-4.3 (which requires that if, subsequent to an annual filing, changes occur so that the information contained in
the filing is no longer accurate, the MEWA, association, or intermediary that made the filing shall,
within fifteen days
of the date the change is effective, file the changes with the Department), when the update is made within the annual
filing year.
Annual filings are due on the first anniversary of licensure and on July 1 every year thereafter.
Please complete all fields to avoid delay in processing. Attach additional pages as needed.
☐ This is an annual Filing ☐ This is an update to an Annual Filing
(place an “X” beside the information that is being updated and the date
on which the information changed)
Information
updated
with this
submission?
If yes, place
“X” here.
Date on
which
information
changed
☐
__/__/____
1. Name of Association or MEWA: __________________________________
☐
☐
☐
☐
☐
__/__/____
__/__/____
__/__/____
__/__/____
__/__/____
2. Names and business addresses of all principals, officers, directors, and
trustees of the Association or MEWA:
a. _______________________________________________________
b. _______________________________________________________
c. _______________________________________________________
d. _______________________________________________________
e. _______________________________________________________
☐
☐
☐
☐
☐
__/__/____
__/__/____
__/__/____
__/__/____
__/__/____
3. Names and addresses of the employer members:
a. _______________________________________________________
b. _______________________________________________________
c. _______________________________________________________
d. _______________________________________________________
e. _______________________________________________________
Annual Renewal | 2
☐
☐
☐
☐
☐
__/__/____
__/__/____
__/__/____
__/__/____
__/__/____
4. Names and addresses of trustees or other persons responsible for the
MEWA's or the Association's operation:
a. _______________________________________________________
b. _______________________________________________________
c. _______________________________________________________
d. _______________________________________________________
e. _______________________________________________________
☐
☐
☐
__/__/____
__/__/____
__/__/____
5. List the contact information for where communications are to be received
for the Company:
a. Mailing address: _________________________________________
b. Email address: __________________________________________
c. Telephone number: ______________________________________
☐
__/__/____
6. Set forth the eligibility requirements for membership in the Association or
MEWA (add additional pages if more space is needed):
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
☐
__/__/____
7. Are fees charged for membership in the Association or MEWA;
YES ☐ or NO ☐.
If yes, please provide details of the fee structure, including amounts charged:
________________________________________________________________
☐
__/__/____
8. Are the Association or MEWA’s benefits or coverage fully insured;
YES ☐ or NO ☐
If no, please provide explanation:
____________________________________________
☐
__/__/____
9. List the name of the insurer that insures the Association or MEWA:
_______________________________________________________
Annual Renewal | 3
☐
☐
☐
☐
☐
☐
__/__/____
__/__/____
__/__/____
__/__/____
__/__/____
__/__/____
10. Does the Association or MEWA meet all of the following requirements of a
“bona fide association” set forth in 18 Del. C. § 3506(a)?
a. Has been actively in existence for at least 5 years YES ☐ or NO ☐
b. Has been formed and maintained in good faith for purposes other
than obtaining insurance and does not condition membership on the
purchase of association-sponsored insurance YES ☐ or NO ☐
c. Does not condition membership in the association on any health
status-related factor relating to an individual (including an employee
of an employer or a dependent of an employee) and clearly so states
in all membership and application materials YES ☐ or NO ☐
d. Makes health insurance coverage offered through the association
available to all members regardless of any health status-related
factor relating to such members (or individuals eligible for coverage
through a member) and clearly so states in all marketing and
application materials YES ☐ or NO ☐
e. Does not make health insurance coverage offered through the
association available other than in connection with a member of the
association and clearly so states in all marketing and application
materials YES ☐ or NO ☐
f. Provides and annually updates information necessary for the
Commissioner to determine whether or not an association meets the
definition of a bona fide association before qualifying as a bona fide
association for the purposes of this chapter. YES ☐ or NO ☐
If no, please provide an explanation:
_____________________________________________________________
Annual Renewal | 4
☐
☐
☐
__/__/____
__/__/____
__/__/____
11. Is the insurance policy offered by the Association or MEWA in compliance
with the following requirements as set forth in 18 Del. C. § 3506(b)?
a. The policy may insure members of such association or associations,
employees thereof or employees of members or 1 or more of the
preceding or all of any class or classes thereof for the benefit of
persons other than the employer YES ☐ or NO ☐
b. The premium for the policy shall be paid from funds contributed by
the association or associations or by the employer members, or by
both, or from funds contributed by the covered persons or from both
the covered persons and the association, associations or employer
members. YES ☐ or NO ☐
c. A policy on which no part of the premium is to be derived from
funds contributed by the covered persons specifically for their
insurance must insure all eligible persons, except those who reject
such coverage in writing. YES ☐ or NO ☐
If no, please provide an explanation:
________________________________________________________________
☐
__/__/____
12. Describe the Association or MEWA’s membership requirements:
_____________________________________________________________
☐
__/__/____
13. List the names, addresses, and qualifications of persons who will solicit,
negotiate, procure, or effect applications for coverage with the association
or MEWA:
Name: _______________________________________________________
Address: _____________________________________________________
Qualifications_________________________________________________
Name: _______________________________________________________
Address: _____________________________________________________
Qualifications_________________________________________________
Annual Renewal | 5
☐
☐
☐
__/__/____
__/__/____
__/__/____
14. List the names and addresses of all administrators and organizations,
including third party administrators or intermediaries, responsible for the
operation of the Association or MEWA that complies with the following:
• The Association or MEWA contact shall be the person responsible
for filing all applicable forms and changes in information with the
Department:
Name: ___________________________________________
Address: _________________________________________
Role: TPA ☐, Intermediary ☐, Other ☐. If other, please
specify:
Name: ___________________________________________
Address: _________________________________________
Role: TPA ☐, Intermediary ☐, Other ☐. If other, please
specify: __________________________________________
• The regulatory contact shall be the person responsible for receiving
notice of laws regulations, bulletins, and the like that may affect
the plan. Complete and attach Form D2.
Name: ___________________________________________
Address: _________________________________________
☐
__/__/____
15. Does the insurer offering the health benefit plan to the association or a
MEWA shall guarantee acceptance of all persons within the association or
MEWA and their dependents as required by 18 DE Admin. Code § 7.5?
YES ☐ or NO ☐
☐
__/__/____
16. Does the health benefit plan provide all of the benefits listed in 18 DE
Admin. Code § 8.0? YES ☐ or NO ☐
☐
__/__/____
17. Does the health benefit plan meet all of the membership requirements of 18
DE Admin. Code § 9.0? YES ☐ or NO ☐
☐
__/__/____
18. Does the health benefit plan comply with the notice requirements of 18 DE
Admin. Code § 10.0? YES ☐ or NO ☐
☐
__/__/____
19. Does the health benefit plan comply with the enrollment requirements in 18
DE Admin. Code § 11.0 and 18 Del. C. § 3571J? YES ☐ or NO ☐
Annual Renewal | 6
☐
__/__/____
20. Attach a copy of each of the following documents:
a. Any policy or contract describing the benefits offered by the
Association or MEWA.
b. The organizational documents of the Association or MEWA,
including but not limited to:
i. Articles of incorporation;
ii. By-laws; or
iii. Trust instrument;
c. The Association or MEWA's certificate of good standing from the
state in which association or MEWA is registered as a business;
d. Any document executed by an employer to become a member of the
Association, including application for membership in the
association;
e. The biographical affidavits for all trustees, officers, directors, and
other members of the Association or MEWA's governing body who
are responsible for the operation of the Association or MEWA;
f. All current policies or contracts of insurance issued to the
Association or MEWA that provide coverage for health care
benefits and services to be offered in Delaware.;
g. All current contracts between the Association or MEWA and
insurers to provide coverage for health care benefits and services to
be offered in Delaware;
h. All current advertising and marketing materials used by the
association or MEWA;
i. A completed UCAA Form 12 (registered agent for service of
process form).
j. The most recent audited financial statement as defined in 18 DE.
Admin. Code § 1405-12.0.
k. The most recent M-1 form as filed with United States Department of
Labor.
l. Documentation of the Association’s or MEWA’s annual premium
for the preceding policy year and an estimate of its annual premium
for the following year.
m. A certified copy of a surety bond sufficient to cover 20% of the
Association’s or MEWA’s annual premium for Delaware members
that is in a form to be approved by the Commissioner and has been
issued by an insurer or surety licensed to transact such business in
Delaware, or by a surplus lines insurer on Delaware's approved list.
21. Send the completed application and all supporting documents electronically to
BERG@delaware.gov.
Annual Renewal | 7
22. Remit filing fee in the amount of $150 by check, made payable to Delaware
Department of Insurance (checks with an incorrect payee will be rejected).
Mail to:
Delaware Department of Insurance
Attn: BERG
841 Silver Lake Blvd.
Dover, DE 19904
Note that the time frames for Department review set forth in 18 DE. Admin. Code §
1405-4.4 and 4.5 will begin on the date that the Department receives the applicant’s
check, not from the date that the Department receives the application by email.
The Undersigned hereby swear and affirm that the foregoing statements and information
regarding _______________________________________________are true and correct.
(Name of Association/MEWA)
__________________________________ ____________
Signature of Officer, Director, or Trustee Date
__________________________________
Printed Name
State of )
)ss:
County of )
Sworn before me this ______ day of ________________,_____
____________________________________
Notary Public
My Commission Expires: ________
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Annual Renewal | 8
The Undersigned hereby swear and affirm that the foregoing statements and information
regarding _______________________________________________are true and correct.
(Name of Association/MEWA)
__________________________________ ____________
Signature of Plan Intermediary Date
__________________________________
Printed Name
State of )
)ss:
County of )
Sworn before me this ______ day of ________________,_____
____________________________________
Notary Public
My Commission Expires: ________
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Multiple Employer Welfare Arrangements (MEWA) Annual Filing for (Department of Technology and Information)

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Completed 13 August 2020

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