Rules and Regulations of the State of Georgia
 

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firefox Mozilla Firefox

  1. In the address bar, type about:config and press Enter.
  2. Click "I'll be careful, I promise" if a warning message appears.
  3. In the search box, search for javascript.enabled
  4. Toggle the "javascript.enabled" preference (right-click and select "Toggle" or double-click the preference) to change the value from "false" to "true".
  5. Click on the "Reload current page" button of the web browser to refresh the page.
  • 1. In the address bar, type about:config and press Enter.
  • 2. Click "I'll be careful, I promise" if a warning message appears.
  • 3. In the search box, search for javascript.enabled
  • 4. Toggle the "javascript.enabled" preference (right-click and select "Toggle" or double-click the preference) to change the value from "false" to "true".
  • 5. Click on the "Reload current page" button of the web browser to refresh the page.




ie Internet Explorer

  1. On web browser menu click "Tools" icon and select "Internet Options".
  2. In the "Internet Options" window select the "Security" tab.
  3. On the "Security" tab click on the "Custom level..." button.
  4. When the "Security Settings - Internet Zone" dialog window opens, look for the "Scripting" section.
  5. In the "Active Scripting" item select "Enable".
  6. When the "Warning!" window pops out asking "Are you sure you want to change the settings for this zone?" select "Yes".
  7. In the "Internet Options" window click on the "OK" button to close it.
  8. Click on the "Refresh" button of the web browser to refresh the page.
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 Internet Explorer < 9
  1. On web browser menu click "Tools" and select "Internet Options"
  2. In the "Internet Options" window select the "Security" tab.
  3. On the "Security" tab click on the "Custom level..." button.
  4. When the "Security Settings - Internet Zone" dialog window opens, look for the "Scripting" section.
  5. In the "Active Scripting" item select "Enable".
  6. When the "Warning!" window pops out asking "Are you sure you want to change the settings for this zone?" select "Yes".
  7. In the "Internet Options" window click on the "OK" button to close it.
  8. Click on the "Refresh" button of the web browser to refresh the page.
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chrome Google Chrome

  1. On the web browser menu click on the "Customize and control Google Chrome" and select "Settings".
  2. In the "Settings" section click on the "Show advanced settings..."
  3. Under the the "Privacy" click on the "Content settings...".
  4. When the dialog window opens, look for the "JavaScript" section and select "Allow all sites to run JavaScript (recommended)".
  5. Click on the "OK" button to close it.
  6. Close the "Settings" tab.
  7. Click on the "Reload this page" button of the web browser to refresh the page.
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opera Opera

  • 1. a) Click on "Menu", hover mouse on the "Settings" then hover mouse on the "Quick preferences" and mark the "Enable Javascript" checkbox.
  • 1. b) If "Menu bar" is shown click on the "Tools", hover mouse on the "Quick preferences" and mark the "Enable Javascript" checkbox.
1. a) opera10 a 1. b) opera10 b




safari Apple Safari

  1. On the web browser menu click on the "Edit" and select "Preferences".
  2. In the "Preferences" window select the "Security" tab.
  3. In the "Security" tab section "Web content" mark the "Enable JavaScript" checkbox.
  4. Click on the "Reload the current page" button of the web browser to refresh the page.
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<xmp>.</xmp> <form name="form1" method="post" action="120-2-50?urlRedirected=yes&amp;data=admin&amp;lookingfor=120-2-50" id="form1"> <input type="hidden" name="__VIEWSTATE" id="__VIEWSTATE" value="/wEPDwUKLTY5ODkwOTM2Nw8WAh4Ec3BhbQIFFgJmD2QWAgIFDw8WAh4EVGV4dAUFNCArIDFkZGQPvJCDcW4djbLiqwcwPmpXTOAVwg==" /> <input type="hidden" name="__VIEWSTATEGENERATOR" id="__VIEWSTATEGENERATOR" value="EEBB6393" /> <input type="hidden" name="__EVENTVALIDATION" id="__EVENTVALIDATION" value="/wEWCAKUoK7JDALniKOhBALV5cpNAoa5iIEFAoznisYGAsrv5u0MAsrv4u0MAsrv3u0MgrTExsqblsLWLt8/LdsPwVXtPfA=" /> <div class='popup'> <div class='cnt223'> <div style="margin-bottom:6px;"> <img alt="Rules and Regulations of the State of Georgia" src="/images/new.gif"/> </div> <div class="header"> Terms and Conditions of Agreement for Access to Rules and Regulations of the State of Georgia Website </div> <div class="scroll"> <p>(Note: certain features of this site have been disabled for the general public to prevent digital piracy. If you are an entitled government entity pursuant the Georgia Administrative Procedures Act, <a target="_new" href="http://links.casemakerlegal.com/states/GA/books/Code_of_Georgia/browse?ci=25id=gasos&amp;codesec=50-13-7&amp;title=50&amp;#50-13-7(d)">O.C.G.A.§ 50-13-7(d)</a> contact the State of Georgia's Administrative Procedures Division at 678-364-3785 to enable these features for your location.)</p> <p>To access this website, you must agree to the following: </p> <p> These terms of use are a contract between you and/or your employer (if any), and Lawriter, LLC. </p> <p> You agree that you will not copy, print, or download anything from this website for any commercial use. </p> <p> You agree not to use any web crawler, scraper, or other robot or automated program or device to obtain data from the website.</p> <p> You agree that you will not sell, will not license, and will not otherwise make available in exchange for anything of value, anything that you download, print, or copy from this site.</p> <p> You agree that you will not copy, print, or download any portion of the regulations posted on this site exceeding a single chapter of regulations for sale, license, or other transfer to a third party, except that you may quote a reasonable portion of the regulations in the course of rendering professional advice.</p> <p> If you violate this agreement, or if you access or use this website in violation of this agreement, you agree that Lawriter will suffer damages of at least $20,000. </p> <p> THIS WEBSITE AND ITS CONTENT ARE PROVIDED "AS IS." THE STATE OF GEORGIA AND LAWRITER EXPRESSLY DISCLAIM ALL WARRANTIES, INCLUDING THE WARRANTIES OF MERCHANTABILITY, FITNESS FOR A PARTICULAR PURPOSE, AND NON-INFRINGEMENT AND ARE NOT LIABLE TO ANY PERSON FOR ANY ERRORS IN INACCURACIES CONTAINED IN THIS WEBSITE. </p> <p> If you accept these terms enter the information below and click “I AGREE”.</p> </div> <table border="0" style="width: 810px"> <tr> </tr> <tr> <td style="vertical-align: text-top; width: 243px;"> Full Name:</td> <td style="width: 532px; vertical-align:super;"> <input name="firstName" type="text" id="firstName" class="txt" /> <span id="lbl_fname"><font color="Red"></font></span> </td> </tr> <tr><td style="width: 243px"> Human verification: <b> <span id="lblStopSpam">4 + 1</span>&nbsp;= </b></td><td style="width: 532px"> <input name="captcha" type="text" id="captcha" class="txt" /> <span id="lbl_captcha"><font color="Red"></font></span> &nbsp; <input name="sum" type="hidden" id="sum" value="5" /> </td></tr> </table> <input type="submit" name="Button1" value="I AGREE" id="Button1" disabled="disabled" /> <span id="alrtmsg"><font color="Red"></font></span> <input name="v1" type="hidden" id="v1" /> <input name="v2" type="hidden" id="v2" /> <input name="v3" type="hidden" id="v3" /> <p>Privacy Policy: the above information is for internal use only as related to this agreement and will not be sold or distributed.</p> </div> </div> </form> <html> <head runat="server"> <title>GA - GAC</title> <link href="_files/main.css" media="all" rel="Stylesheet" type="text/css" /> <link href="_files/treeview_old.css" media="all" rel="Stylesheet" type="text/css" /> <link href="/_files/popup.css" media="all" rel="stylesheet" type="text/css" /> <script type="text/javascript" src="/_files/treeview.js"></script> <script type="text/javascript" src="/_files/jquery-1.8.0.min.js"></script> <script type="text/javascript" src="/_files/jquery-1.10.2.js"></script> <script type="text/javascript" src="/_files/popup.js"></script> <script type="text/javascript" src="http://code.jquery.com/jquery-1.8.2.js"></script> <script type="text/javascript" src="https://ajax.googleapis.com/ajax/libs/jquery/1.8/jquery.min.js" /> <script type="text/javascript" src="/_files/jquery.popup.js"></script> <script type="text/javascript" src="/_files/jquery.popup.min.js"></script> <script type="text/javascript" src="/_files/ValidateForm.js"></script> <script src="https://code.jquery.com/jquery-1.11.3.js"></script> <link href="/_files/enablejs.css" rel="Stylesheet" type="text/css" /> <link href="/_files/forJavascript.css" rel="Stylesheet" type="text/css" /> <style type="text/css"> .collapse{background-image:url('/images/expcoll_right.png');} .expand{background-image:url('/images/expcoll_down.png');} </style> <script type="text/javascript"> $(document).ready(function(){ $("#History-parent").click(function(){ $("#History-Childs").toggle(); if ($('#History-parent img').hasClass('expand')) { $('#History-parent img').addClass('collapse'); $('#History-parent img').removeClass('expand'); $('#History-parent img').attr('src', '/images/expcoll_right.png'); } else { $('#History-parent img').removeClass('collapse'); $('#History-parent img').addClass('expand'); $('#History-parent img').attr('src', '/images/expcoll_down.png'); } }); $("#History-Childs").hide(); var tocnode=document.getElementById('toc-children'); if (tocnode != null) { if(tocnode.childNodes.length != 0) { document.getElementById("doc-content").style.width="72%"; document.getElementById("toc").style.width="21%"; document.getElementById("toc").style.padding="10px"; } else { document.getElementById('toc').style.display="none"; } } }); function fnsetRDVal(id) { if (id=="y") { document.getElementById("y").value="yes" document.getElementById("n").value="" } else { document.getElementById("n").value="no" document.getElementById("y").value="" } } </script> <script type="text/javascript"> function TermsCon() { var overlay = $('<div id="overlay"></div>'); overlay.show(); overlay.appendTo(document.body); $('.popup2').show(); $('#btnAgree').click(function () { $('.popup2').hide(); $("#overlay").hide(); overlay.appendTo(document.body).remove(); }); $("#btnprint").click(function () { var contents = $("#popupterms").html(); var frame1 = $('<iframe />'); frame1[0].name = "frame1"; frame1.css({ "position": "absolute", "top": "-1000000px" }); $("body").append(frame1); var frameDoc = frame1[0].contentWindow ? 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If you are an entitled government entity pursuant the Georgia Administrative Procedures Act, <a target="_new" href="http://links.casemakerlegal.com/states/GA/books/Code_of_Georgia/browse?ci=25id=gasos&amp;codesec=50-13-7&amp;title=50&amp;#50-13-7(d)">O.C.G.A.§ 50-13-7(d)</a> contact the State of Georgia's Administrative Procedures Division at 678-364-3785 to enable these features for your location.)</p> <p>To access this website, you must agree to the following: </p> <p> These terms of use are a contract between you and/or your employer (if any), and Lawriter, LLC. </p> <p> You agree not to use any web crawler, scraper, or other robot or automated program or device to obtain data from the website. </p> <p> You agree that you will not sell or license anything that you download, print, or copy from this website.</p> <p> THIS WEBSITE AND ITS CONTENT ARE PROVIDED "AS IS." THE STATE OF GEORGIA AND LAWRITER EXPRESSLY DISCLAIM ALL WARRANTIES, INCLUDING THE WARRANTIES OF MERCHANTABILITY, FITNESS FOR A PARTICULAR PURPOSE, AND NON-INFRINGEMENT AND ARE NOT LIABLE TO ANY PERSON FOR ANY ERRORS IN INACCURACIES CONTAINED IN THIS WEBSITE. </p> <p> By accessing and/or using this website, you agree to the terms and conditions above. If you do not agree to the terms and conditions above, you must cease accessing and/or using this website and destroy all material obtained from this website without your agreement. </p> </div> </div> <div class="modal-footer"> <input type="button" name="btnAgree" value="Close" id="btnAgree" class="btn-blue noprint" /> <input type="button" name="btnprint" value="Print" id="btnprint" class="btn-blue noprint" /> </div> </div> </div> <div id="main" class="noprint"> <!--class="noprint"--> <div id="header" class="noprint"> <div class="container"> <div class="terms"> NOTICE OF TERMS OF USE OF THIS WEBSITE. 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Chapter 33-50 and to ensure the safe and proper operation of multiple employer self-insured health plans in Georgia.</P> <h2><a href="/GAC/120-2-50-.02" name="120-2-50-.02" title="120-2-50-.02">Rule 120-2-50-.02 Definitions</a></h2> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-50-.02(1)">(1)</a></td> <td valign="top" style="text-align:left" class="leftalign"> "Employee" means any person in the service of another under any contract of hire, express or implied, oral or written, where the employer has the power or right to control and direct the employee in the material details of how the work is to be performed.</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-50-.02(2)">(2)</a></td> <td valign="top" style="text-align:left" class="leftalign"> "Employer" means any person who employs the services of others or for whom the employees work.</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-50-.02(3)">(3)</a></td> <td valign="top" style="text-align:left" class="leftalign"> "Premium" means the consideration for insurance, by whatever name called. Any assessment, or any membership, policy, survey, inspection, or similar fee or charge in consideration for an insurance contract is deemed part of the premium.</td> </tr> </table> <h2><a href="/GAC/120-2-50-.03" name="120-2-50-.03" title="120-2-50-.03">Rule 120-2-50-.03 Disclosure</a></h2> <P>Any person who advertises, solicits, sells, transacts, or administers coverage, or who in any manner secures, helps or aids in the placing or administration of coverage with any multiple employer self-insured plan in Georgia shall prominently disclose in writing to every participating employer, covered employee, and employer being solicited for participation, in a form to be filed with and approved by the Commissioner at the time of licensing, the following: that the plan is a self-insured plan and that benefits are not guaranteed by a licensed insurer; that the plan is not covered by the Georgia Life and Health Guaranty Association which provides protection to Georgia residents from insolvent insurers; and that certain other major protections offered to Georgia residents under the Georgia Insurance Code and Rules and Regulations, such as conversion rights and certain mandated or required benefits, may not be available through the multiple employer self-insured plan.</P> <h2><a href="/GAC/120-2-50-.04" name="120-2-50-.04" title="120-2-50-.04">Rule 120-2-50-.04 Filing Requirements</a></h2> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-50-.04(1)">(1)</a></td> <td valign="top" style="text-align:left" class="leftalign"> All communications and filings must be made with the Regulatory Services Division, Georgia Insurance Department. To Complete the application for a license, the following items pertaining to the plan must be submitted: <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-50-.04(1)(a)">(a)</a></td> <td valign="top" style="text-align:left" class="leftalign"> Each applicant for license shall make application on form ME-2, entitled "Application for License for Multiple Employer Self-Insured Health Plan," attached hereto as "Exhibit A" and incorporated herein.</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-50-.04(1)(b)">(b)</a></td> <td valign="top" style="text-align:left" class="leftalign"> A copy of the plan's bylaws, all schedules of benefits, and all management, administration and trust agreements which the plan has made or proposes to make for the conduct of its business and affairs, certified to by a majority of the trustees. Any proposed change or amendment to the foregoing must also be filed with the Commissioner not less than sixty (60) days before the effective date of the change or amendment.</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-50-.04(1)(c)">(c)</a></td> <td valign="top" style="text-align:left" class="leftalign"> An audited financial statement prepared by a certified public accountant (CPA), on form ME-3, entitled "Financial Statement," attached hereto as "Exhibit B" and incorporated herein.</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-50-.04(1)(d)">(d)</a></td> <td valign="top" style="text-align:left" class="leftalign"> Signed and notarized biographical affidavits by all trustees of the plan on form ME-4, entitled "Biographical Questionnaire," attached hereto as "Exhibit C" and incorporated herein.</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-50-.04(1)(e)">(e)</a></td> <td valign="top" style="text-align:left" class="leftalign"> A complete list of names, addresses, and telephone numbers of employers participating in the plan and the number of employees of each employer participating in the plan.</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-50-.04(1)(f)">(f)</a></td> <td valign="top" style="text-align:left" class="leftalign"> A statement of the reasons for applying for a Georgia license, a description of exactly how the plan proposes to develop and Supervise its operations in Georgia, the name, title and qualifications of the person who will be responsible for the plan's operation in Georgia, and the location of and a description of the office facilities that will be provided by the plan in Georgia.</td> </tr> </table> </td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-50-.04(2)">(2)</a></td> <td valign="top" style="text-align:left" class="leftalign"> After the plan has complied with the above requirements, the application file will be reviewed and the Commissioner will request any additional information as in his discretion he may deem proper for considering the plan's application for a license.</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-50-.04(3)">(3)</a></td> <td valign="top" style="text-align:left" class="leftalign"> While an application is pending, it is the responsibility of the plan to keep all required statements, documents and materials current.</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-50-.04(4)">(4)</a></td> <td valign="top" style="text-align:left" class="leftalign"> An application for a license in Georgia is not complete until the plan has complied, to the Commissioner's satisfaction, with all of the above requirements. The Commissioner is not required to act formally on an incomplete application.</td> </tr> </table> <h2><a href="/GAC/120-2-50-.05" name="120-2-50-.05" title="120-2-50-.05">Rule 120-2-50-.05 Stop-Loss Coverage Requirements</a></h2> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-50-.05(1)">(1)</a></td> <td valign="top" style="text-align:left" class="leftalign"> A multiple employer self-insured health plan is required to obtain individual and aggregate excess stop-loss coverage from an insurer authorized to transact insurance in Georgia. Such coverage must be submitted for approval by the Commissioner.</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-50-.05(2)">(2)</a></td> <td valign="top" style="text-align:left" class="leftalign"> Plan participants are required to find benefits up to the point at which the excess stop-loss insurer assumes one hundred percent of the liability to pay benefits. In reviewing an excess stop-loss agreement for approval, the Commissioner will closely scrutinize the agreement to determine whether the levels of individual and aggregate risk retained by the plan are such as will put the plan in an unsound condition or will render its proceedings hazardous to the public or to persons covered under the plan. In making his determination, the Commissioner will consider all relevant factors including, but not limited to, reserving practices, adequacy of employer/employee contributions, benefits provided under the plan, administrative and other expenses, and management. If the Commissioner is of the opinion that the excess stop-loss agreement will put the plan in an unsound condition, will render the plan's proceedings hazardous to the public or persons covered under the plan, or is otherwise not in compliance with the law, the Commissioner will disapprove the agreement.</td> </tr> </table> <h2><a href="/GAC/120-2-50-.06" name="120-2-50-.06" title="120-2-50-.06">Rule 120-2-50-.06 Security Deposits</a></h2> <P>Security Deposit in the amount of $100,000 shall be made with the Commissioner on forms GID-5A through GID-6, as applicable. Referenced forms are attached to Rules and Regulations of the Georgia Insurance Department, Section <a title="120-2-18" href="120-2-18">120-2-18</a>-.04, Exhibits B and C, and are hereby incorporated herein by reference. The following types of security deposits are acceptable:</P> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-50-.06(a)">(a)</a></td> <td valign="top" style="text-align:left" class="leftalign"> Securities having a market value of not less than $100,000 registered in the name of the plan, both as to principal and interest, with forms GID-5A and GID-6. Forms GID-5B and 5C are not required with the deposit of U.S. Treasury Bonds or Notes.</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-50-.06(b)">(b)</a></td> <td valign="top" style="text-align:left" class="leftalign"> Certificates of Deposit in Georgia banks in an amount of $100,000, and for a duration of at least one year unless automatically renewable, with form GID-6.</td> </tr> </table> <h2><a href="/GAC/120-2-50-.07" name="120-2-50-.07" title="120-2-50-.07">Rule 120-2-50-.07 Examinations</a></h2> <P>An examination will be performed by the Commissioner to verify the books, accounts and records underlying the plan during the licensing process. This examination will be performed at the expense of the applicant by a representative of the Office of the Commissioner of Insurance. After licensure, plans will be subject to periodic unscheduled and unannounced examinations in accordance with O.C.G.A. Chapter 33-2.</P> <h2><a href="/GAC/120-2-50-.08" name="120-2-50-.08" title="120-2-50-.08">Rule 120-2-50-.08 Powers of Attorney</a></h2> <P>A power of attorney appointing a person who is a resident of Georgia to receive service of legal process must be submitted on form ME-5 entitled "Power of Attorney," attached hereto as "Exhibit D" and incorporated herein. Such person must be readily accessible and available for service. Both the residence and business address must be provided.</P> <h2><a href="/GAC/120-2-50-.09" name="120-2-50-.09" title="120-2-50-.09">Rule 120-2-50-.09 Bonds</a></h2> <P>Proof of bonding by a surety company having a certificate of authority to transact insurance in Georgia in a minimum amount of $150,000 for each plan trustee must be submitted.</P> <h2><a href="/GAC/120-2-50-.10" name="120-2-50-.10" title="120-2-50-.10">Rule 120-2-50-.10 Surplus</a></h2> <P>A detailed statement of the method used to arrive at the plan's required surplus account as required in Section <a href="https://links.casemakerlegal.com/states/ga/books/Code_of_Georgia/browse?ci=25&amp;id=gasos&amp;codesec=33-50-7&amp;title=33#33-50-7(b)" target="_newtab">33-50-7(b)</a>must be submitted.</P> <h2><a href="/GAC/120-2-50-.11" name="120-2-50-.11" title="120-2-50-.11">Rule 120-2-50-.11 Loss Reserves</a></h2> <P>The plan must establish and maintain loss reserves in an amount deemed appropriate by the Commissioner. Plans in existence and actually operating in a sound manner for a period of at least 3 years prior to July 1, 1991, may maintain a reserve amount, which combined with surplus, will be 35% of claims paid by such plan in the immediate preceding year. The 35% level combined surplus/reserve may be deemed appropriate by the Commissioner so long as a determination is made that the insured employees/employer plan is in sound financial condition.</P> <h2><a href="/GAC/120-2-50-.12" name="120-2-50-.12" title="120-2-50-.12">Rule 120-2-50-.12 Fees</a></h2> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-50-.12(1)">(1)</a></td> <td valign="top" style="text-align:left" class="leftalign"> Any application for a license shall be accompanied by a fee as provided in O.C.G.A. Sec. <a href="https://links.casemakerlegal.com/states/ga/books/Code_of_Georgia/browse?ci=25&amp;id=gasos&amp;codesec=33-8-1&amp;title=33#" target="_newtab">33-8-1</a>. This fee is nonrefundable.</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-50-.12(2)">(2)</a></td> <td valign="top" style="text-align:left" class="leftalign"> An annual license fee as provided in O.C.G.A. Sec. <a href="https://links.casemakerlegal.com/states/ga/books/Code_of_Georgia/browse?ci=25&amp;id=gasos&amp;codesec=33-8-1&amp;title=33#" target="_newtab">33-8-1</a>, payable to the Georgia Commissioner of Insurance, is required upon licensing and on or before July 1 of each year. The first license period is from the date of licensing through the following June 30th. The license fee will not be prorated for a period of less than one year.</td> </tr> </table> <h2><a href="/GAC/120-2-50-.13" name="120-2-50-.13" title="120-2-50-.13">Rule 120-2-50-.13 Reporting Requirements</a></h2> <P>A multiple employer self- insured health plan is required to file, on or before March 1st of each year, a signed and certified statement of its condition and affairs as of the preceding December 31st, on form ME-3. A plan is further required to furnish any additional information concerning its business and affairs which the Commissioner or his representatives shall require.</P> <h2><a href="/GAC/120-2-50-.14" name="120-2-50-.14" title="120-2-50-.14">Rule 120-2-50-.14 Dissolution</a></h2> <P>Any application to dissolve must be made on form ME-6, entitled "Application for Dissolution," attached hereto as "Exhibit E" and incorporated herein. An application for dissolution will not be considered to have been received by the Commissioner until it has been completed to his satisfaction.</P> <h2><a href="/GAC/120-2-50-.15" name="120-2-50-.15" title="120-2-50-.15">Rule 120-2-50-.15 Penalties</a></h2> <P>Any person failing to comply with the requirements of this Regulation shall be subject to such penalties as may be appropriate under the insurance laws of Georgia.</P> <h2><a href="/GAC/120-2-50-.16" name="120-2-50-.16" title="120-2-50-.16">Rule 120-2-50-.16 Severability</a></h2> <P>If any provision of this Regulation, or the application thereof to any person or circumstance, is held invalid by a court of competent jurisdiction, the remainder of the Regulation and the applicability of such provision to other persons or circumstances shall not be affected thereby.</P> <P>EXHIBIT A</P> <P>OFFICE OF COMMISSIONER OF INSURANCE STATE OF GEORGIA</P> <P> APPLICATION FOR LICENSE FOR MULTIPLE EMPLOYER SELF-INSURED HEALTH PLAN</P> <P>To the Commissioner of Insurance of the State of Georgia: ____________________________________________________________ </P> <P>(Name of Plan) domiciled in the State of ___________________ and whose home or principal office is located in the City of ______________ and State of ___________________ by its Trustees hereby make application for a license to transact business as a Multiple Employer Self-Insured Health Plan in the State of Georgia for the period ending June 30, 19_____.</P> <P>1. Name of Plan and Federal Employer Identification (EIN) number ______________.</P> <P>2. Street Address __________________________________________</P> <P>3. Post Office Box (if applicable) _________________________</P> <P>4. City _____________________ State ________________________ Zip _______________</P> <P>5. Date plan organized _____________________________________ Has the plan been in continuous operation since that time? </P> <P>Yes _______ No ______ If "no," explain why not___________ ________________________________________________________ ________________________________________________________</P> <P>6. Form of Organization: __________________________________ ________________________________________________________ (Trust, Corporation, Partnership, etc.)</P> <P>7. Date Plan began business: ______________________________ ________________________________________________________</P> <P>8. Number of employers participating ______________________ ________________________________________________________</P> <P>9. Type(s) of business(es) of participating employers _____ ________________________________________________________ ________________________________________________________ ________________________________________________________</P> <P>10. Name and address of sponsoring organization or association, if any ____________________________________ ________________________________________________________ ________________________________________________________</P> <P>11. Number of employees covered ____________________________ ________________________________________________________ ________________________________________________________</P> <P>12. Give the names and addresses of plan trustees, the employers which they represent, and the licensed surety company(ies) by which they are bonded (including bond numbers): </P> <P>Name Address Employer Surety Bond</P> <P>Represented Name Number </P> <P>a. ________________________________________________________</P> <P>b. ________________________________________________________</P> <P>c. ________________________________________________________</P> <P>d. ________________________________________________________</P> <P>e. ________________________________________________________</P> <P>f. ________________________________________________________</P> <P>g. ________________________________________________________</P> <P>13. Name and address of licensed investment manager ________ ________________________________________________________ ________________________________________________________</P> <P>14. Name and address of plan administrator, if any _________ ________________________________________________________ ________________________________________________________ </P> <P>Describe the duties which the administrator performs on behalf of the plan _____________________________________ ________________________________________________________ ________________________________________________________</P> <P>15. In what states is the administrator licensed? (Please provide all license numbers)____________________________ ________________________________________________________ ________________________________________________________</P> <P>16. Has this plan ever been the subject of any administrative investigation or disciplinary action, by any insurance regulatory authority? Yes ______ No _____. </P> <P>If "yes", provide details and attach copies of all orders and pertinent documentation.</P> <P>17. Has this plan ever surrendered a license or entered into a Consent Order to avoid disciplinary proceedings by any insurance regulatory authority? Yes _______ No _____. If "yes", provide details and attach copies of all surrenders, orders, and other pertinent documentation.</P> <P>18. List all states other than Georgia where the plan transacts business _____________________________________ ________________________________________________________ ________________________________________________________ ________________________________________________________</P> <P>19. List all states other than Georgia in which the plan is licensed in any manner by any regulatory authority, giving the type of license held and the name of the official or agency issuing the license: </P> <P>State Type of license Issuing official or agency </P> <P>a. _____________________________________________________</P> <P>b. _____________________________________________________</P> <P>c. _____________________________________________________</P> <P>d. _____________________________________________________ </P> <P>(use additional page if necessary)</P> <P>20. Identify benefits provided employees: </P> <P>Accident and Health () Dental ()</P> <P>Short-Term Disability () Other ()</P> <P>Specify ________________________________________________</P> <P>21. State the reasons the plan is applying for a Georgia license, a description of exactly how the plan proposes to develop and supervise its operations in Georgia, the name, title and qualifications of the person who will be responsible for the plan's operation in Georgia, and the location of and a description of the office facilities that will be provided by the plan in Georgia. </P> <P>________________________________________________________</P> <P>________________________________________________________</P> <P>________________________________________________________</P> <P>________________________________________________________</P> <P>________________________________________________________</P> <P>________________________________________________________</P> <P>________________________________________________________</P> <P>________________________________________________________</P> <P>(Attach additional sheets if needed)</P> <P>22. Attached to this Application, and incorporated herein by reference, are the following: </P> <P>a. Copy of the plan's bylaws, all schedules of benefits, and all management, administration and trust agreements which the plan has made or proposes to make for the conduct of its business and affairs, certified by a majority of the trustees.</P> <P>b. An audited financial statement, prepared by a certified public accountant (CPA), on form ME-3.</P> <P>c. A complete list of the names, addresses, Federal Employer Identification Numbers, and telephone numbers of all employers participating in the plan, and the number of employees of each employer.</P> <P>d. A copy of individual and aggregate excess stop-loss policy or policies covering the plan.</P> <P>e. A power of attorney appointing a Georgia resident to receive legal process (Form ME-5).</P> <P>f. Proof of bonding of trustees as required in Rule <a title="120-2-50-.09" href="120-2-50-.09">120-2-50-.09</a>.</P> <P>g. Proposed disclosure statement as required in Rule <a title="120-2-50-.03" href="120-2-50-.03">120-2-50-.03</a>.</P> <P>h. A check for the applicable filing fee, made payable to the Georgia Commissioner of Insurance.</P> <P>CERTIFICATION</P> <P>We, ____________________________________________________ ____________________________________________________________ __________ , the undersigned, constituting a majority of the Trustees of ________________________________________________ ____________________________________________________________ ____________________________________________________________</P> <P>(Name of Multiple Employer Self-Insured Health Plan) swear that to the best of our knowledge and belief, the statements contained in the foregoing application for license, including all documents attached hereto, are true and complete.</P> <P>COUNTY OF ________________</P> <P>STATE OF _________________</P> <P>BY: __________________</P> <P>(Name of Trustee)</P> <P>Sworn to before me this _______ day of _______________ 19___.</P> <P>_____________________________</P> <P>NOTARY PUBLIC</P> <P>My Commission Expires</P> <P>______________________________</P> <P>COUNTY OF _____________</P> <P>STATE OF ________________</P> <P>BY: __________________</P> <P>(Name of Trustee)</P> <P>Sworn to before me this</P> <P>_______ day of _______________ 19 _____.</P> <P>_____________________________</P> <P>NOTARY PUBLIC</P> <P>My Commission Expires ______________________________</P> <P>COUNTY OF ____________________</P> <P>STATE OF _____________________</P> <P>BY: __________________</P> <P>(Name of Trustee)</P> <P>Sworn to before me this</P> <P>_______ day of _______________ 19 ______.</P> <P>_____________________________</P> <P>NOTARY PUBLIC</P> <P>My Commission Expires _____________________________</P> <P>COUNTY OF _____________</P> <P>STATE OF _______________</P> <P>BY: __________________</P> <P>(Name of Trustee)</P> <P>Sworn to before me this</P> <P>_______ day of _______________ 19_______.</P> <P>_____________________________</P> <P>NOTARY PUBLIC</P> <P>My Commission Expires _____________________________</P> <P>EXHIBIT B</P> <P>OFFICE OF COMMISSIONER OF INSURANCE STATE OF GEORGIA</P> <P> FINANCIAL STATEMENT MULTIPLE EMPLOYER SELF-INSURED HEALTH PLANS</P> <P><B>INSTRUCTIONS</B> ____________________________________________________________ ___________________________________________________________</P> <P><B>General Instructions.</B> The financial statement consists of four basic statements:</P> <P>1) balance sheet;</P> <P>2) statement of income, expenses and surplus;</P> <P>3) statement of changes in financial position; and</P> <P>4) schedule of investments. </P> <P>A plan's financial statements must be in conformance with these instructions. They may deviate from the prescribed format for the purpose of increasing the quality of the information. For example, an entry may be broken into more detailed subparts. Blank lines are provided for this purpose, or for adding entries. In general, whenever the meaning of an entry may be unclear, a footnote explanation should be provided. Footnotes are an integral part of the financial statement.</P> <P>____________________________________________________________</P> <P>____________________________________________________________</P> <P><B>BALANCE SHEET</B></P> <P>1. <B>Cash on hand and on deposit.</B> This is coin, currency, and the balance in accounts with banks or other financial institutions.</P> <P>2. <B>Bonds.</B> This is the value of all fixed period, interest bearing securities, including bonds, certificates of deposit, commercial paper, and similar investments. Such securities shall be valued at their actual cost, excluding accrued interest.</P> <P>3. <B>Stocks.</B> This is the value of all securities representing equity interest in commercial entities, including common stock and preferred stock. Such securities shall be valued at their market value. </P> <P>4-6. List here any investments not fitting the other categories in this section.</P> <P>7. Enter the total of items 1 through 6.</P> <P>8. <B>Premiums due and unpaid.</B> This is the amount of premiums owed by plan members but not yet paid. Premium should not be considered due until the inception of the period to which the premium applies.</P> <P>9. <B>Assessments due and unpaid.</B> This is the amount of assessments owed by plan members but not yet paid. Assessments may be to increase plan surplus or to correct a deficit.</P> <P>10. <B>Penalties due and unpaid.</B> This is the amount of penalties levied against plan members pursuant to the plan's rules and bylaws, but not yet paid.</P> <P>11. <B>Investment income due and accrued.</B> This is the amount of dividends declared and interest accrued on plan investments, but not yet received or credited to plan accounts.</P> <P>12. <B>Third party reimbursements receivable.</B> This is the amount owed the plan on account of losses it has paid, for which it is entitled to reimbursement through subrogation, coordination of benefits, return of overpayments, or similar recovery actions.</P> <P>13. <B>Amounts recoverable from stop loss insurers.</B></P> <P>This is the amount the plan is entitled to recover under its stop loss insurance, but which has not yet been paid. This is the total recoverable under both individual and aggregate access coverage, based on the plan's current level of losses paid and incurred but unpaid claims.</P> <P>14. <B>Prepaid expenses.</B> This is the portion of any expenses which the plan has paid, for which the value has not yet been received. Prepaid expenses for services applicable to fixed periods of time, such as stop loss insurance, shall be valued according to the percentage of unelapsed time in the period to which the payment is applicable. Other prepaid expenses shall be valued according to the portion of the service which has not yet been received. </P> <P>15-16. List here any assets not fitting the other categories in this section.</P> <P>17. Enter the total of items 8 through 16.</P> <P>18. Enter the total of items 7 and 17.</P> <P>19. <B>Reserve for unearned and advance premiums.</B> This is the portion of all premiums which have not yet been earned. Premium is earned as the period of time to which the premium applies elapses. This reserve includes: </P> <P>(A) All advanced premiums, namely, premiums paid prior to the inception of the period to which they apply.</P> <P>(B) For coverage in force, the percentage of premium corresponding to the unelapsed time in the period to which the premium applies. For example, if premiums are paid monthly, half-way through any month one-half of the corresponding premium payment would be unearned.</P> <P>20. <B>Reserve for outstanding losses - reported.</B> This is the plan's best estimate of the amount it will be obligated to pay for known loss occurrences or continuing courses of treatment. This reserve includes:</P> <P>(A) Claims awaiting payment, for which checks have not yet been issued.</P> <P>(B) The estimated final cost of claims subject to investigation, litigation, or negotiations (explain in footnote). For claims where liability is disputed or the amount uncertain, the estimated cost should be a weighted value of the possible outcomes. For example, if there is a 51% chance the plan will win a dispute and owe nothing, but a 49% chance it will lose and owe $10,000, the estimated cost should be closer to $5,000 than to zero.</P> <P>(C) The estimated cost associated with covered persons undergoing a continuing course of treatment or a continuing disability for which the plan will likely be liable, notwithstanding that treatment has not yet been provided or that the period of disability has not yet occurred. For example, a person covered by the plan develops cancer and will undergo a lengthy course of treatment. If it is likely that the plan will continue to have responsibility for the person during the course of treatment, an appropriate reserve should be established.</P> <P>21. <B>Reserve for outstanding losses - IBNR.</B> This is the plan's best estimate of the amount it will be obligated to pay for loss occurrences that have not yet been reported (incurred but not reported). At any given time, persons covered by the plan will be incurring treatment and submitting bills or becoming disabled, and claims staff will be at various stages of evaluating claims that have been received. The IBNR reserve should be reasonably sufficient to cover such outstanding liability, based on staff judgment and the plan's actual experience overtime.</P> <P>22. List here any reserve not fitting the other categories in this section.</P> <P>23. Enter the total of items 19 through 22.</P> <P>24. <B>Stop loss premiums due and unpaid.</B> This is the amount of all stop loss premiums, for individual excess, aggregate excess, and incurred runoff excess if applicable, that the plan owes but has not yet paid.</P> <P>25. <B>Stop loss aggregate advancement.</B> This applies only to plans with an aggregate advancement clause in their stop loss insurance contract. This is the amount of funds advanced or loaned to the plan from the stop loss insurer, that have not yet been repaid, or that have not yet been determined to be an actual obligation of the aggregate excess stop loss insurer.</P> <P>26. <B>Commissions due or accrued.</B> This is the amount of commissions to agents or brokers that the plan owes but has not yet paid.</P> <P>27. <B>Other expenses due or accrued.</B> This is the amount of all expenses not listed elsewhere that the plan owes but has not yet paid.</P> <P>28. <B>Georgia license fees due or accrued.</B> This is the amount of license fees that the plan owes to the State of Georgia but has not yet paid.</P> <P>29. <B>Federal income taxes due or accrued.</B> This is the amount of federal taxes on the plan's income that the plan owes but has not yet paid.</P> <P>30. <B>Federal capital gains taxes due or accrued.</B></P> <P>This is the amount of federal taxes on capital gains on plan investment transactions, that the plan owes but has not yet paid.</P> <P>31. <B>Dividends declared and unpaid.</B> This is the amount of dividends that have been declared, but that have not yet been paid to or claimed by members. </P> <P>32-34. List here any liabilities not fitting the other categories in this section.</P> <P>35. Enter the total of items 24 through 34.</P> <P>36. Enter the total of items 23 and 35.</P> <P>37. <B>Contributed surplus.</B> This is the amount contributed by the members to provide capital for operation, to correct a deficit; to increase the plan's working capital to forestall a deficit; or to otherwise ease operations.</P> <P>38. <B>Retained earnings.</B> This is the amount of plan earnings from operations and unrealized capital gains that is retained and not paid out as dividends. This amount is initially zero, and is subsequently adjusted by each year's statement of income, expenses and surplus, item 38.</P> <P>39. List here any surplus item not fitting the other categories in this section.</P> <P>40. Enter the total of items 37 through 39.</P> <P>41. Enter the total of items 36 and 40.</P> <P><B>STATEMENT OF INCOME, EXPENSES AND SURPLUS</B></P> <P>This statement contemplates that income and expenses will be calculated on an accrual basis, rather than a cash basis.</P> <P>For income, this generally means that income is recognized for the current fund year if the service was provided or the payment was earned during the fund year, regardless of whether cash has been received. For expenses, this generally means that losses or expenses are recognized for the current fund year if the obligation was incurred during the fund year, regardless of whether cash as been paid. Even if not explicitly stated in each instruction, all income and expenses should be taken to apply to transactions occurring during the current fund year.</P> <P>1. <B>Gross premiums written.</B> This is the amount of premiums written by the plan for coverage during the current fund year. This amount should be net of any discounts or adjustments to premium. Premium should not be considered written or booked until the inception of the period to which the premium applies.</P> <P>2. <B>Individual excess stop expense.</B> This is the amount of premiums paid or incurred for individual excess stop loss insurance.</P> <P>3. <B>Aggregate excess stop loss expense.</B> This is the amount of premiums paid or incurred for aggregate excess stop loss insurance, including extended or runoff aggregate excess coverage.</P> <P>4. <B>Change in reserve for unearned and advance</B><B>premiums.</B> This is the net change in the amount reported one year ago on line 19 of the balance sheet. This and items 9, 10, 38, and 39 are negative entries only if the net change is an increase, otherwise they would be positive.</P> <P>5. Enter the total of items 1 through 4.</P> <P>6. <B>Losses paid.</B> This is the total amount of losses (claims) paid during the current fund year.</P> <P>7. <B>Third party reimbursements.</B> This is the amount determined during the current fund year of reimbursements owed to the plan and which the plan expects to recover, through subrogation, coordination of benefits, return of over payments, or similar recovery actions. Cash need not have been received during the current fund year.</P> <P>8. <B>Recovered from stop loss insurers.</B> This is the amount determined during the current fund year of reimbursements owed to the plan on account of its stop loss insurance policies. Cash need not have been received during the current fund year.</P> <P>9. <B>Change in reserve for outstanding losses - reported.</B></P> <P>This is the net change in the amount reported one year ago on line 20 of the balance sheet. If there is a net increase, enter the amount as a negative number. A net decrease would be a positive entry.</P> <P>10. <B>Change in reserve for outstanding losses - IBNR.</B> This is the net change in the amount reported one year ago on line 21 of the balance sheet. If there is a net increase, enter the amount as a negative number. A net decrease would be a positive entry.</P> <P>11. Enter the total of items 6 through 10.</P> <P>12. Enter the total of items 5 and 11.</P> <P>13. <B>Interest income.</B> This is the amount of interest earned during the current fund year on the accounts and investments of the plan.</P> <P>14. <B>Dividend income.</B> This is the amount of dividends earned during the current fund year on investments of the plan.</P> <P>15. <B>Net realized capital gains (losses).</B> This is the total net gain or loss on the disposition of any plan assets during the current fund year. For the purpose of calculating a net gain or loss, the base value of the asset should be its carrying value on the balance sheet. Unrealized capital gains reported online 36 of previous statements should not be double-counted in reporting realized capital gains.</P> <P>16. <B>Penalties assessed.</B> This is the amount of penalties levied against plan members pursuant to the plan's rules and bylaws during the current fund year. </P> <P>17-18. List here any income not fitting the other categories in this section.</P> <P>19. Enter the total of items 13 through 18.</P> <P>20. Enter the total items 12 and 19.</P> <P>21. <B>Service company expenses.</B> This is the amount incurred during the current fund year for the services of the plan's service company and subcontractors.</P> <P>22. <B>Financial administrator expenses.</B> This is the amount incurred during the current fund year for the services of the plan's financial administrator.</P> <P>23. Agent commissions expenses. This is the amount incurred during the current fund year for agent and broker commissions.</P> <P>24. <B>Board of trustees expenses.</B> This is the amount incurred during the current year for board of trustees expenses.</P> <P>25. <B>Fidelity bond expenses.</B> This is the amount incurred during the current fund year for fidelity bonds and similar coverages.</P> <P>26. <B>License fees incurred.</B> This is the amount incurred during the current fund year for Georgia license fees.</P> <P>27. <B>Federal capital gains taxes incurred.</B> This is the amount of federal taxes on capital gains on plan investment transactions incurred during the current fund year. </P> <P>28-29. List here any expenses not fitting the other categories in this section.</P> <P>30. Enter the total of items 21 through 29.</P> <P>31. Enter the result of subtracting item 30 from item 20.</P> <P>32. <B>Federal income taxes incurred.</B> This is the amount of federal taxes on the plan's income incurred during the current fund year.</P> <P>33. Enter the results of subtracting item 32 from item 31. </P> <P>34. <B>Total surplus, end of previous year.</B> This is the amount from item 47 of the previous year's statement of income, expenses and Surplus.</P> <P>35. <B>After tax gain from operations.</B> From item 33 of this statement.</P> <P>36. <B>Net unrealized capital gains (losses).</B> This is the total net gain or loss on plan assets owned as of this reporting, that is, not disposed of. For the purpose of calculating a net gain or loss, the base value of the asset should be whatever value it was carried at on the balance sheet as of the last reporting. The initial base value would be the purchase price; subsequently the balance sheet base value would be adjusted each year the asset was held to reflect unrealized capital gains and losses as the asset's value changes.</P> <P>37. <B>Dividends declared.</B> This is the amount of dividends declared by the plan during the current fund year.</P> <P>38. Enter the total of items 35 through 37.</P> <P>39. <B>Contributed surplus and assessments.</B> This is the amount levied against or pledged by plan members during the current fund year to correct a deficit and/or increase the surplus. </P> <P>40-44. List here any items affecting surplus not fitting the other categories in this section.</P> <P>45. Enter the total of items 39 through 44.</P> <P>46. Enter the total of items 38 and 45.</P> <P>47. Enter the total of items 34 and 46.</P> <P><B>STATEMENT OF CHANGES IN FINANCIAL POSITION</B></P> <P>1. <B>Before tax gain (loss) from operations.</B> This is the amount from line 31 of the statement of income, expenses and surplus.</P> <P>2-9. <B>Increase (decrease) in various liabilities.</B> This is the net change in the amount reported one year ago on the balance sheet for these liabilities. Changes in these liabilities affect income and expenses, but do not affect funds.</P> <P>10-11. List here any other liabilities affecting income and expenses but not funds, not fitting the other categories in this section.</P> <P>12-16. <B>Decrease (increase) in various assets.</B> This is the net change in the amount reported one year ago on the balance sheet for these assets. Changes in these assets affect income and expenses, but do not affect funds.</P> <P>17-18. List here any other assets affecting income and expenses but not funds, not fitting the other categories in this section.</P> <P>19. Enter the total of items 1 through 18.</P> <P>20. <B>Bonds.</B> This is the amount received upon the sale, maturation, or disposition of all fixed period, interest bearing securities, including bonds, certificates of deposit, commercial paper, and similar investments. Such investments acquired and disposed of during the year should be reported in item 22.</P> <P>21. <B>Stocks.</B> This is the amount received upon the sale or disposition of all securities representing equity interest in commercial entities, including stock and preferred stock. Such investments acquired and disposed of during the year should be reported in item 22.</P> <P>22. <B>Net gain (loss) on investments acquired and disposed of during year.</B> This is the total net gain or loss on assets acquired and disposed of during the year. For the purpose of calculating a net gain or loss, the base value of the asset should be its purchase price. </P> <P>23-24. List here any investments sold, matured, or repaid, not fitting the other categories in this section.</P> <P>25. Enter the total of items 20 through 24.</P> <P>26. <B>Decrease (increase) in prepaid expenses.</B> This is the net change in the amount reported one year ago on line 14 of the balance sheet.</P> <P>27. <B>Increase (decrease) in federal income taxes due or accrued.</B> This is the net change in the amount reported one year ago on line 31 of the balance sheet.</P> <P>28. <B>Stop loss aggregate advancement received (repaid).</B> This is the net amount of funds advanced or loaned to the plan from the stop loss insurer that have not yet been determined to be an actual obligation of the aggregate excess stop loss insurer, and funds repaid to the stop loss insurer pursuant to such an advance.</P> <P>29. <B>Contributed surplus and assessments.</B> This is the amount of funds received during the fund year from assessments or other contributions to surplus from plan members. This should be equal to the net decrease (increase) in item 9 of the balance sheet, plus item 39 of the statement of income, expenses and surplus. </P> <P>30-31. List here any other sources of funds provided not fitting the other categories in this section.</P> <P>32. Enter the total of items 26 through 31.</P> <P>33. Enter the total of items 19, 25, and 32.</P> <P>34. <B>Bonds.</B> This is the amount expended for the acquisition of all fixed period, interest bearing securities, including bonds, certificates of deposit, commercial paper, and similar investments. This should include the amount expensed for accrued interest, and exclude the amount expended for investments acquired and disposed of during the fund year.</P> <P>35. <B>Stocks.</B> This is the amount expended for the acquisition of all securities representing equity interest in commercial entities, including stock and preferred stock. This should exclude the amount expended for investments acquired and disposed of during the fund year. </P> <P>36-37. List here any investments acquired not fitting the other categories in this section.</P> <P>38. Enter the total of items 34 through 37.</P> <P>39. <B>Dividends paid.</B> This is the amount of dividends paid to members during the fund year. This should be equal to the net decrease (increase) in item 31 of the balance sheet, plus item 37 of the statement of income, expenses and surplus. </P> <P>40-41. List here any other uses of funds not fitting the other categories in this section.</P> <P>42. Enter the total of items 39 through 41.</P> <P>43. Enter the total of items 38 and 42.</P> <P>44. <B>Cash on hand and on deposit, beginning of year.</B> This is the amount from item 1 of the balance sheet as of the end of the previous year.</P> <P>45. <B>Increase (decrease) in cash.</B> This is the result of subtracting item 43 from item 33.</P> <P>46. <B>Cash on hand and on deposit, year to date.</B> This is the total of items 44 and 45.</P> <P><B>SCHEDULE OF INVESTMENTS</B></P> <P>No form is provided for the schedule of investments. Plans should submit the required information using their own format. Please note that under O.C.G.A. Chapter 33-11 and Section <a href="https://links.casemakerlegal.com/states/ga/books/Code_of_Georgia/browse?ci=25&amp;id=gasos&amp;codesec=33-50-6&amp;title=33#33-50-6(3)" target="_newtab">33-50-6(3)</a>, plans are restricted in the types of depositories, bonds, stocks, and other investments they may employ.</P> <P><B>Cash on hand and on deposit.</B> The schedule must contain a description of all accounts or depositories maintained by the plan at banks or other financial institutions. The description must contain:</P> <P>(1) the institution's name and location;</P> <P>(2) the account balance as of this reporting;</P> <P>(3) the type of account;</P> <P>(4) the interest rate, if any, that money in the account earns;</P> <P>(5) a statement as to whether funds in the account are wholly or partially insured; and</P> <P>(6) a statement as to which plan contractors have access to the account or depository, and on what conditions.</P> <P><B>Bonds.</B> The schedule must contain a description of all fixed period, interest bearing securities, including bonds, certificates of deposit, commercial paper, and similar investments. The description must contain:</P> <P>(1) the issuer's name and location;</P> <P>(2) the type of security;</P> <P>(3) the interest rate, and the months in which interest is paid;</P> <P>(4) the year of acquisition, and the security's maturity month/year;</P> <P>(5) the actual cost of the security, excluding accrued interest;</P> <P>(6) the security's par value; and</P> <P>(7) the month sold or disposed of; for all securities sold or disposed of during the current fund year, including securities acquired during the year.</P> <P><B>Stocks.</B> The schedule must contain a description of all securities representing equity interest in commercial entities including common stock and preferred stock. The description must contain:</P> <P>(1) the entity's name and location;</P> <P>(2) the type of security;</P> <P>(3) the year of acquisition;</P> <P>(4) the number of shares;</P> <P>(5) the current market value per share;</P> <P>(6) the total market value of identical securities;</P> <P>(7) the actual cost of the security; and</P> <P>(8) the month sold or disposed of; for all securities sold or disposed of during the current fund year, including securities acquired during the year.</P> <P><B>Other investments.</B> The schedule must contain a description of all investments not fitting the above categories. The information provided about such investments should be comparable to the information required above.</P> <P> <P><img class="ImageLink" src="/pdf/ga/admin/2019/120-2-50-.16_001.jpg" alt=" image: ga/admin/2019/120-2-50-.16_001.jpg"></P> </P> <P> <P><img class="ImageLink" src="/pdf/ga/admin/2019/120-2-50-.16_002.jpg" alt=" image: ga/admin/2019/120-2-50-.16_002.jpg"></P> </P> <P> <P><img class="ImageLink" src="/pdf/ga/admin/2019/120-2-50-.16_003.jpg" alt=" image: ga/admin/2019/120-2-50-.16_003.jpg"></P> </P> <P>EXHIBIT C</P> <P>OFFICE OF COMMISSIONER OF INSURANCE STATE OF GEORGIA</P> <P> BIOGRAPHICAL QUESTIONNAIRE</P> <P>1. Name _________________________________________________</P> <P>2. Office Held __________________________________________</P> <P>3. Individual's Name ____________________________________</P> <P> Date of Birth _____________</P> <P> Place of Birth____________ </P> <P>Social Security Number _______________________________</P> <P>4. Current Residential Address __________________________</P> <P>5. Current Business Address _____________________________</P> <P>6. Residential address for past five (5) years </P> <P>a. ___________________________________________________</P> <P>b. ___________________________________________________</P> <P>c. ___________________________________________________</P> <P>d. ___________________________________________________</P> <P>e. ___________________________________________________</P> <P>7. Education (beyond secondary schools) </P> <P>______________________________________________________ ______________________________________________________ ______________________________________________________ ______________________________________________________</P> <P>8. Employment History. (Beginning with current employer, trace back complete history. Show dates of employment, name and address of company, position held, and duties.) </P> <P>______________________________________________________</P> <P>______________________________________________________</P> <P>______________________________________________________</P> <P>______________________________________________________</P> <P>9. List any other companies which you now serve, or within the past five (5) years have served, as either an officer or director. (List company, position and dates.) </P> <P>______________________________________________________</P> <P>______________________________________________________</P> <P>______________________________________________________</P> <P>10. Have you ever been charged with a criminal violation </P> <P>(other than traffic offense) at any time?_____________</P> <P>If "yes", provide complete details.</P> <P>______________________________________________________</P> <P>______________________________________________________</P> <P>______________________________________________________</P> <P>______________________________________________________</P> <P>11. Have you ever held any other license (except a driver's license)? If "Yes", provide details as to any such license. If any such license was ever suspended, revoked, or renewal thereof refused, please explain and attach supporting documentation. </P> <P>______________________________________________________</P> <P>______________________________________________________</P> <P>______________________________________________________</P> <P>______________________________________________________</P> <P>12. Have you ever been charged by any regulatory agency, City, County, State or Federal, with having violated any laws, rules or regulations? Has any company been so charged, allegedly as a result of any action or conduct on your part? _______________ If "yes" as to either, submit full details including disposition of charge. </P> <P>______________________________________________________</P> <P>______________________________________________________</P> <P>______________________________________________________</P> <P>______________________________________________________</P> <P>_______________ 19 ____ ______________________________</P> <P>Date Signature</P> <P>State of __________________) ss.</P> <P>County of _________________)</P> <P>On the ___________________ day of, 19___, before me, a Notary Public in and for the State and County aforesaid, personally appeared ____________________ to me known to be the individual described in and who executed the aforegoing and did make oath in due form of law that the matters and facts contained in the foregoing resume are true and correct.</P> <P>_______________________________</P> <P>NOTARY PUBLIC</P> <P>EXHIBIT D OFFICE OF COMMISSIONER OF INSURANCE STATE OF GEORGIA</P> <P> POWER OF ATTORNEY</P> <P> KNOW ALL MEN BY THESE PRESENTS,</P> <P>That the_______________ Multiple Employer Self-Insured health plan (hereinafter "Plan") of _______________________ State of _________________ * does hereby make, constitute and appoint ____________________________________________________________ ____________________________________________________________</P> <P>Business Address</P> <P>____________________________________________________________</P> <P>Street # and Name (P.O. Box not acceptable)</P> <P>City County Zip Code</P> <P>Home Address</P> <P>____________________________________________________________</P> <P>(Street number and name) (City) (County) (Zip Code)</P> <P>its true and lawful Attorney in and for the State of Georgia, on whom all process of law, whether mense or final, against said Plan may be served in any action or special proceedings against said Plan in the State of Georgia, subject to and in accordance with all the provisions of the statutes and laws of said State of Georgia now in force, and such other Acts as may be hereafter passed amendatory thereof and supplementary thereto; and the said Attorney is duly authorized and empowered as the agent of said Plan to receive and accept service of process in all cases provided by the laws of the State of Georgia, and such service shall be deemed valid personal service upon said Plan.</P> <P>* Has the above name and/or address of the appointment changed since the last ME-5 was filed? Yes_____ No_____</P> <P>________________________</P> <P>Trustee</P> <P>State of _____________________</P> <P>County of ____________________</P> <P>Sworn to and subscribed before me _______________this day of</P> <P>__________________________, 19 ____</P> <P>______________________</P> <P>Notary Public</P> <P>EXHIBIT E</P> <P>OFFICE OF COMMISSIONER OF INSURANCE STATE OF GEORGIA</P> <P> APPLICATION FOR DISSOLUTION</P> <P>To the Commissioner of Insurance of the State of Georgia: ____________________________________________________________</P> <P>(Name of Plan)</P> <P>hereby applies for dissolution pursuant to O.C.G.A. Section <a href="https://links.casemakerlegal.com/states/ga/books/Code_of_Georgia/browse?ci=25&amp;id=gasos&amp;codesec=33-50-9&amp;title=33#" target="_newtab">33-50-9</a>. The following information is submitted:</P> <P>1. Name, address, and state of domicile.</P> <P>2. Date plan was first licensed in Georgia.</P> <P>3. Number of employers participating.</P> <P>4. Name and address of sponsoring organization, if any.</P> <P>5. Number of employees covered.</P> <P>6. (If applicable) Name and address of licensed insurer which has made an irrevocable commitment which provides for payment of all outstanding liabilities and for providing all related services, including payment of claims, preparation of reports, and administration of transactions associated with the period when the plan provided coverage. </P> <P>The following items must be attached:</P> <P>a) A current, audited financial statement, form ME-3, certified by a Certified Public Accountant.</P> <P>b) A current list of names, addresses, telephone numbers, and current number of employees for each employer covered under the plan.</P> <P>c) Evidence of an irrevocable commitment from a licensed insurer, if application is made pursuant to O.C.G.A. Section <a href="https://links.casemakerlegal.com/states/ga/books/Code_of_Georgia/browse?ci=25&amp;id=gasos&amp;codesec=33-50-9&amp;title=33#33-50-9(a)(2)" target="_newtab">33-50-9(a)(2)</a>.</P> <P>d) A proposed plan for distribution of assets to participating employers in accordance with O.C.G.A. </P> <P>Section <a href="https://links.casemakerlegal.com/states/ga/books/Code_of_Georgia/browse?ci=25&amp;id=gasos&amp;codesec=33-50-9&amp;title=33#33-50-9(b)" target="_newtab">33-50-9(b)</a>.</P> <P>NOTE: If the Commissioner approves this application for dissolution, the plan must submit evidence satisfactory to the Commissioner that said distribution has been made, within sixty (60) days of such approval. Failure to submit said evidence shall be deemed to be dissolution without authority.</P> <P>CERTIFICATION</P> <P>We, ______________________________________________________ ____________________________________________________________ the undersigned, constituting a majority of the Trustees of ____________________________________________________________ swear that to the best of our knowledge and belief, the statements contained in the foregoing application for dissolution, including all documents attached hereto, are true and complete.</P> <P>COUNTY OF_________________</P> <P>STATE OF _________________</P> <P>BY:____________________</P> <P>(Name of Trustee)</P> <P>Sworn to before me this</P> <P>________day of____________</P> <P>19____.</P> <P>__________________________</P> <P>NOTARY PUBLIC</P> <P>My Commission Expires</P> <P>__________________________</P> <P>COUNTY OF__________________</P> <P>STATE OF __________________</P> <P>BY:______________________</P> <P>(Name of Trustee)</P> <P>Sworn to before me this</P> <P>________day of_____________ 19___.</P> <P>___________________________</P> <P>NOTARY PUBLIC</P> <P>My Commission Expires</P> <P>___________________________</P> <P>COUNTY OF__________________</P> <P>STATE OF___________________</P> <P>BY:______________________</P> <P>(Name of Trustee)</P> <P>Sworn to before me this</P> <P>________day of____________ 19___.</P> <P>__________________________</P> <P>NOTARY PUBLIC</P> <P>My Commission Expires __________________________</P> <P>COUNTY OF_____________________</P> <P>STATE OF _____________________</P> <P>BY:____________________</P> <P>(Name of Trustee)</P> <P>Sworn to before me this</P> <P>___________day of____________ 19_____.</P> <P>_____________________________</P> <P>NOTARY PUBLIC</P> <P>My Commission Expires</P> <P>_____________________________</P> </div> </div> </HTML> </div> <div id="toc" class="sidebar noprint"> <ul id="toc-children" class="children"><li><a href="/GAC/120-2-50-.01" name="120-2-50-.01" title="120-2-50-.01">Rule 120-2-50-.01 Purpose</a></li><li><a href="/GAC/120-2-50-.02" name="120-2-50-.02" title="120-2-50-.02">Rule 120-2-50-.02 Definitions</a></li><li><a href="/GAC/120-2-50-.03" name="120-2-50-.03" title="120-2-50-.03">Rule 120-2-50-.03 Disclosure</a></li><li><a href="/GAC/120-2-50-.04" name="120-2-50-.04" title="120-2-50-.04">Rule 120-2-50-.04 Filing Requirements</a></li><li><a href="/GAC/120-2-50-.05" name="120-2-50-.05" title="120-2-50-.05">Rule 120-2-50-.05 Stop-Loss Coverage Requirements</a></li><li><a href="/GAC/120-2-50-.06" name="120-2-50-.06" title="120-2-50-.06">Rule 120-2-50-.06 Security Deposits</a></li><li><a href="/GAC/120-2-50-.07" name="120-2-50-.07" title="120-2-50-.07">Rule 120-2-50-.07 Examinations</a></li><li><a href="/GAC/120-2-50-.08" name="120-2-50-.08" title="120-2-50-.08">Rule 120-2-50-.08 Powers of Attorney</a></li><li><a href="/GAC/120-2-50-.09" name="120-2-50-.09" title="120-2-50-.09">Rule 120-2-50-.09 Bonds</a></li><li><a href="/GAC/120-2-50-.10" name="120-2-50-.10" title="120-2-50-.10">Rule 120-2-50-.10 Surplus</a></li><li><a href="/GAC/120-2-50-.11" name="120-2-50-.11" title="120-2-50-.11">Rule 120-2-50-.11 Loss Reserves</a></li><li><a href="/GAC/120-2-50-.12" name="120-2-50-.12" title="120-2-50-.12">Rule 120-2-50-.12 Fees</a></li><li><a href="/GAC/120-2-50-.13" name="120-2-50-.13" title="120-2-50-.13">Rule 120-2-50-.13 Reporting Requirements</a></li><li><a href="/GAC/120-2-50-.14" name="120-2-50-.14" title="120-2-50-.14">Rule 120-2-50-.14 Dissolution</a></li><li><a href="/GAC/120-2-50-.15" name="120-2-50-.15" title="120-2-50-.15">Rule 120-2-50-.15 Penalties</a></li><li><a href="/GAC/120-2-50-.16" name="120-2-50-.16" title="120-2-50-.16">Rule 120-2-50-.16 Severability</a></li></ul> </div> </div> <!--content ends here--> <div id="footer" class="noprint"><span class="footer">Copyright &copy; 2019 Lawriter LLC - All rights reserved.</span>| <a href="mailto:support@casemakerlegal.com?subject=Rules and Regulations of the State of Georgia">Email Us</a> | 844-838-0769 | <a href="http://livechat.casemakerlegal.com/client.php?locale=en" target="_blank" onclick="if(navigator.userAgent.toLowerCase().indexOf('opera') != -1 && window.event.preventDefault)window.event.preventDefault();this.newWindow = window.open('http://livechat.casemakerlegal.com/client.php?locale=en&url='+escape(document.location.href)+'&referrer='+escape(document.referrer), 'webim','toolbar=0,scrollbars=0,location=0,status=1,menubar=0,width=640,height=480,resizable=1');this.newWindow.focus();this.newWindow.opener=window;return false;">Live Chat</a> </div> </div> </body> </html>