Discount Medical Plan Organization Renewal Form: Form …
|[pic] |Department of Consumer and Business Services | |
| |Insurance Division – 4 | |
| |P.O. Box 14480, Salem, OR 97309-0405 | |
| |350 Winter St. NE, Salem, Oregon | |
| |Phone: 503-947-7982, Fax: 503-947-7862 | |
| |E-mail: orinsreg.ins@state.or.us | |
| |insurance. | |
| |Discount Medical Plan Organization |
| |Renewal |
| | |
| |
|1. |Name of applicant: | |
|2. |Federal identification number or IRS taxpayer identification number: | |
|3. |Oregon license number: | |
|4. |Mailing address: | |
| |City: | |State: | |ZIP: | |
|5. |Street address (if different): | |
| |City: | |State: | |ZIP: | |
| |Phone: | - - |Fax: | - - |E-mail: | |
|6. |Contact person: | |
| |Phone: | - - |Fax: | - - |E-mail: | |
|7. |Were there any other changes? (Example: Web site, domicile state) Please list: | |
| | |
|8. |During the past year has there been any changes to your registration or license in another state or |
| |jurisdiction? | Yes | No |
| |If yes, please describe: | |
|I, | |certify that I am an officer of the organization |
|named in the foregoing application, that I know the contents thereof, and each of the statements and answers made is true and complete to the best of my knowledge|
|and belief. Further, the organization submits to the jurisdiction of any court of competent jurisdiction in Oregon for the adjudication of any issues arising out |
|of its discount medical plans, agrees to comply with all requirements necessary to give such court jurisdiction, and will abide by the final decision of such |
|court or any appellate court in the event of an appeal. |
| | | | |
| |Date | |Signature |
|Note: A new license is not issued when renewed. We do not normally send confirmation of renewal. If you want confirmation of your renewal please send a stamped, |
|self-addressed envelope with your renewal. |
|[pic] |Discount medical plan organizations must comply with ORS 742.420 through 742.440. |
|440-4793 (10/09/COM) | |
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