| Underwriting Requirements |
| 1. Potential Group Member Questionnaire |
 Download |
| 2. Supplemental Terrorism Application (used to determine employee concentration and surrounding exposure to terrorism) |
Download |
| 3. Letter of Understanding and Appointment of Representative - signed by potential member |
Download |
| Interim Certificate Requirements |
| 4. Formal request to submit to the DIR |
Download |
| 5. Indemnity Agreement and Power of Attorney (DIR form A4-8) - Need separate form for each affiliate or subsidiary with an FEIN Must have original, wet signature. Signature must be notarized |
Download |
| 6. An Authorization Agreement For Direct Payments to be withdrawn from members account. |
Download |
| 7. HCO: Medex Commitment Form |
Download |
| Permanent Certificate Requirements |
| 8. Member Application (DIR form A4-3M) Need separate application for each affiliate or subsidiary with an FEIN Must have original, wet signature |
Download |
| 9. Resolution of Joint and Several - Need separate form for each affiliate or subsidiary with an FEIN Must have original, wet signature |
Download |
| 10. Corporate Resolution to Make submission to DIR |
Download |
| 11. HCFA-COFR signed by potential member-Original Wet Signature |
Download |
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Forms and Applications now available. We've uploaded all of our most frequently requested forms and applications for our producers to download. The forms and applications are available as Adobe PDF files and require the free Adobe Reader.
*Note: Requires the Adobe Acrobat Reader to be viewed.
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