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STATE OF MAINE
Bureau of Insurance
Consumer Health Care Division
#34 State House Station
Augusta, ME 04333-0034

207-624-8475

Overnight delivery:
Deliveries such as FedEx and UPS
76 Northern Ave.
Gardiner, ME 04345.

USPS Express overnight deliveries
34 State House Station
Augusta, ME 04333.

 

Association
Required Information Questionnaire

DIRECTIONS:
The following questions are information the Bureau requires in order to review association groups used in connection with the delivery of life, accident and/or health insurance to the citizens of Maine. This information is required as part of a submission to the Consumer Health Care Division related to an association group plan whether the “association” is sitused in Maine or in another jurisdiction if the association has not been approved previously by the Bureau. 

Provide an answer for each question.

Section A.  General Information:

 

Insurance Company Name:

Maine License #: 

Lead Policy/Certificate Form Number:

Association Name in Full: 

 

Section B.  Contact Information for the Person Responsible for the Association:

 

Name: 

Title: 

Direct Telephone:

Contact Email: 

Mailing Address: 

 

 

Section C. Association Governance/Administration:

  1.  What is the full legal name of the master policyholder? 

 

  1. Where is the association incorporated and domiciled? 

 

  1. What is the association’s principal business address? 

 

  1. How long has the association been in active existence? 

 


 

  1. Who, if not the association’s own employees, conducts the day-to-day business of the association? 

 

  1. How does the association further its purpose as stated in its bylaws? 

 

  1. Does the association hold an annual general membership meeting and/or other membership meetings? 

  YES           NO

  1. When and where was the last membership meeting held and how many members were in attendance? 

 

  1. Are minutes of the meetings held for its members available for inspection for the past two years?

 

  1. What member purposes were discussed and voted upon at meetings during the past two years? 

 

  1. Do all association members have voting privileges and representation on the governing board and committees?

  YES           NO

 

Section D.  Association Membership:

  1.  How does the association determine member eligibility in a manner consistent with its purpose, as described/defined in

        the association bylaws? 

 

  1. Does the Association collect dues from members? 

 

  1.  What percentage of dues-paying members are enrolled in at least one of the association’s insurance product offerings?

 

 

 

Section E.  Documents Requested:

Provide a copy of the following: (Please check box to indicate the item requested is attached.)

  1.     Association articles, bylaws and constitution.

 

  1.   Membership meeting notices sent to members during the past two years.

 

  1.     Association’s membership application, along with the association’s membership underwriting or selection criteria.

 

  1.    Association’s fulfillment package sent to newly enrolled members.

 

 

Last Updated: April 24, 2012