ࡱ>  @ bjbj5*5* W@W@>W_t8888pgpgpg8g$j^Ddm x(.x.x.xz ˉ$R\qez^zee88.x.x[e8.x.xen!6=.xXm @Btpg ) .0^IPP@=8888P=`S5XSSSCKK STATE OF SOUTH CAROLINA DEPARTMENT OF CONSUMER AFFAIRS DISCOUNT MEDICAL PLAN ORGANIZATIONS S.C. Code Ann. 37-17-10 et seq.  HYPERLINK "http://www.scconsumer.gov" www.scconsumer.gov (803) 734-4200 RENEWAL APPLICATION FOR DISCOUNT MEDICAL PLAN ORGANIZATION REGISTRATION (Complete all parts of this Application) Please submit an original of the Application in ring binders. All information should be reduced to 8 x 11 size and arranged with tab inserts numbered accordingly in the order set forth in the Application form. Name of DMPO: FORMTEXT       Registration Certificates for Discount Medical Plan Organizations (DMPOs) in South Carolina are issued annually. The registration period runs from February 1 until January 31 of the following year, and the annual renewal period begins January 1 and ends on January 31 each year. A discount medical plan organization that files its renewal on a timely basis may continue operating unless the registration is denied or revoked by the department. The annual application fee must accompany each application and is NOT refundable. The fee for a DMPO with 0-50 representatives is Five Hundred Dollars ($500.00). The fee for a DMPO with 51-100 representatives is Seven Hundred Fifty Dollars ($750.00). The fee for a DMPO with over 100 representatives is One Thousand Dollars ($1000.00). Applications will not be processed without the required applications fees. An incomplete application will only be held, pending completion, for 90 days following first receipt. If the application has not been completed within 90 days of the Departments receipt of the first application, it will be rejected. The applicant, if it chooses, may submit a new application and fee. The Department will give notice to the applicant as to why the application is incomplete and request additional information. The applicant must submit the information (to complete the application) within 90 days of the Departments first receipt. If the applicant fails to submit the information requested within the allotted time, the application is deemed incomplete and will be rejected. The applicant, if it so chooses, may withdraw the application, within the initial 90 days, if the application is incomplete and it is unable to provide the requested information. The withdrawn application would not be labeled as rejected or denied. Once the withdrawn application is completed, the applicant may resubmit the application and applicable fees as a new application. Please make all checks payable to the South Carolina Department of Consumer Affairs. Pursuant to the provisions of South Carolina Code 37-17-10 et. seq. (2006) as amended, the undersigned hereby makes the following statements for the purpose of REGISTERING to conduct business as a DISCOUNT MEDICAL PLAN Organization (DMPO) in the State of South Carolina: Name of DMPO: FORMTEXT      Date of Organization: FORMTEXT      Federal ID#: FORMTEXT      Business Address: FORMTEXT      City: FORMTEXT      State: FORMTEXT      Zip: FORMTEXT      Telephone: FORMTEXT      Fax: FORMTEXT      Website: FORMTEXT       Name of Primary Contact Person: FORMTEXT      Business Address: FORMTEXT      City: FORMTEXT      State: FORMTEXT      Zip: FORMTEXT      Telephone No.: FORMTEXT      Fax No.: FORMTEXT      E-Mail Address: FORMTEXT       Name of Secondary Contact Person: FORMTEXT      Business Address: FORMTEXT      City: FORMTEXT      State: FORMTEXT      Zip: FORMTEXT      Telephone No.: FORMTEXT      Fax No.: FORMTEXT      E-Mail Address: FORMTEXT       Please provide thirty (30) days advance written notice of any change in any of the above information to the Department. Organizational Structure  FORMCHECKBOX  Corporation FORMCHECKBOX  Limited Liability Company FORMCHECKBOX  General Partnership FORMCHECKBOX  Limited Partnership FORMCHECKBOX  Sole Proprietorship FORMCHECKBOX  Other (specify) FORMTEXT       1. Provide a current organizational chart of the applicant. 2. Provide a current copy of the Certificate of Authorization issued by the South Carolina Secretary of State demonstrating the applicant s authority to conduct business in South Carolina and that all state taxes and fees have been paid. Any business entity that fails to maintain its qualification with the South Carolina Secretary of State forfeits its right to do business in this state and must immediately surrender any registration certificates issued by this Department. 3. Provide the current contact information requested below for the applicants current agent for service of process as registered with the South Carolina Secretary of States office. Name of Current South Carolina Agent for Service of Process: FORMTEXT      Business Address: FORMTEXT      City: FORMTEXT      State: FORMTEXT      Zip: FORMTEXT      Telephone No.: FORMTEXT      Fax No.: FORMTEXT      E-Mail Address: FORMTEXT       4. Attach a photocopy of your most recent license, registration certificate, or certification letter for each state in which the Applicant is currently authorized to provide DMPO services, or any subset, such as prescription drug discount cards. Certifications should be attached in alphabetical order by state. MANAGEMENT In the spaces provided below, provide the requested information for the individuals who are responsible for conducting the applicant DMPOs affairs, including, but not limited to, all members of the board of directors, board of trustees, executive committee, or other governing committee, the officers, contracted management company personnel, and any person or entity owning or having the right to acquire ten percent or more of the voting securities of the applicant. Fill out each section completely. All persons who qualify as a member of applicants management must be listed below. EACH NEW PROPOSED MEMBER OF MANAGEMENT not CURRENTly REGISTERed in South Carolina must each submit a MANAGEMENT BIOGRAPHICAL AFFIDAVIT (Form DMPO-03). Corporations: If the applicant is owned by another corporate entity, list any officers of the parent firm and the ultimate owners (natural persons) in the tables below that qualify management, and attach an organizational chart. Management Based on Ownership: List the names of all persons or entities who directly or indirectly own, control, hold with the power to vote, or hold proxies representing ten percent (10%) or more of the voting securities of the Applicant. Please note whether or not the person or entity is a new member of management since your last application. If necessary, attach additional sheet(s) providing the same information requested below. Full Name And AddressDate of Birth (mm-dd-yyyy)% OwnershipNew? FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       Compliance Note: The Family Independence Act of 1995 requires the South Carolina Department of Social Services Child Enforcement Division (Division) to operate a license revocation program for the purpose of enforcing and establishing child support. In accordance with this Act, South Carolina law ( 20-7-944) requires that all licensing entities submit to the Division licensee data for all new and renewal licenses issued. Therefore, identifying information (i.e., name, social security number and date of birth, etc.) for all members of management licensed with this renewal application will be forwarded to the Division upon the issuance of each renewal license. Personal information will not be used for any other purpose and is not subject to disclosure under the South Carolina Freedom of Information Act. South Carolina Code 30-4-10 et seq. Management Based on Position: List the names and titles/positions of all officers, directors and any person who has direct or indirect control of the organization, including but not limited to contracted management company personnel. Please note whether or not the person or entity is a new member of management since your last application. If necessary, attach additional sheet(s) providing the same information requested below. Full Name And AddressTitle/PositionDate of Birth (mm-dd-yyyy)New? FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       Applicant Business History If any question is answered Yes, attach separate page(s) detailing the circumstances (including any applicable details such as state, license number, dates, etc.) 1. Since your last application, have any of the Applicants existing or proposed management ever been convicted or found guilty of any misdemeanors or felonies (with the exception of minor traffic violations) in any jurisdiction or territory in the United States?  FORMCHECKBOX  Yes  FORMCHECKBOX  No 2. Since your last application, has either the Applicant or any of its existing or proposed management ever been refused a license, registration, or certification as a discount medical plan, or renewal thereof, in any jurisdiction or territory in the United States?  FORMCHECKBOX  Yes  FORMCHECKBOX  No 3. Since your last application, has either the Applicant or any of its existing or proposed management ever had a license revoked, suspended, or otherwise acted against (including probation, fine, or reprimand) in a disciplinary action in any jurisdiction or territory in the United States?  FORMCHECKBOX  Yes  FORMCHECKBOX  No 4. Since your last application, has either the Applicant or any of its existing or proposed management ever been involved in or owned an interest in an organization that has been adjudicated bankrupt, filed proceedings under the Bankruptcy Act, or has otherwise closed due to insolvency?  FORMCHECKBOX  Yes  FORMCHECKBOX  No 5. Since your last application, are any of the licenses, registrations, or certifications of the Applicant or any of its existing or proposed management currently under investigation or currently pending disciplinary action in any jurisdiction or territory in the United States?  FORMCHECKBOX  Yes  FORMCHECKBOX  No 6. Since your last application, has the Applicant or any of its existing or proposed management failed to satisfy any tax liabilities?  FORMCHECKBOX  Yes  FORMCHECKBOX  No 7. Since your last application, has the Applicant or any of its existing or proposed management had a lien or levy placed against it/them?  FORMCHECKBOX  Yes  FORMCHECKBOX  No 8. Since your last application, has the Applicant or any of its existing or proposed management been the subject of an indictment or a cease and desist order in any jurisdiction or territory in the United States?  FORMCHECKBOX  Yes  FORMCHECKBOX  No 9. Since your last application, has the Applicant or any of its existing or proposed management been the subject of a governmental investigation?  FORMCHECKBOX  Yes  FORMCHECKBOX  No 10. Is there any litigation or legal proceeding currently pending or threatened against the Applicant or any of its existing or proposed management in any jurisdiction or territory in the United States?  FORMCHECKBOX  Yes  FORMCHECKBOX  No South Carolina Operations Provide a list of all offices, including branch offices, located in South Carolina:  FORMCHECKBOX  Check if the Applicant has no South Carolina offices. AddressContact PersonTelephone #E-mail address FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       DISCOUNT MEDICAL PLAN OPERATIONS AND MARKETING 1. Attach a list all names (including trade names, brand names, private label names or dbas) used to market the DMPOs discount program. 2. Does the DMPO or any of its marketers include any insurance coverage with the discount program?  FORMCHECKBOX  Yes  FORMCHECKBOX  No 3. If yes, please attach an explanation of the insurance benefits, including the name(s) of the insurer(s). Please submit copies of all policies. 4. Attach current copies of the form of any contract made or to be made between the applicant and any person for the performance on the applicants behalf of any function, including, but not limited to, marketing, administration, enrollment, and subcontracting for the provision of health care services to customers. This should include internal marketing staff as well as external marketers, including call centers. 5. Do your agreements with external marketing companies permit those companies to further subcontract marketing functions to other companies (sub-marketers or private label brands) with or without your approval?  FORMCHECKBOX  Yes  FORMCHECKBOX  No 6. If yes, please attach an explanation of the DMPOs policies and procedures. 7. Provide an organizational chart showing all authorized marketer, sub-marketer, or private label companies and their relationship with the DMPO. 8. Provide copies of all current training materials for marketers and representatives (internal and external). 9 . Attach a statement describing the proposed methods of marketing by the DMPO and its marketers/sub-marketers/private label brands. 10. Provide copies of all marketing materials that will be used in South Carolina and a description of the media (TV, Internet, mass mailing etc.) used for each of the materials submitted. This should include the marketing materials of the DMPO and any authorized marketer or sub-marketer of your plan, including private label brands. All advertisements must contain the name and address of the company offering the service and must conform to the name on file with the Department. In addition, these materials must clearly disclose the amount of all discounts offered. It is important FOR you to verify that all marketing materials meet the requirements of S.C. Code Section 37-17-10 et. seq. before submitting THEM with your application. 11. Does the applicant require its external marketing companies, including private label brands, to get prior approval from the DMPO of their advertising materials?  FORMCHECKBOX  Yes  FORMCHECKBOX  No 12. If yes, attach a description of this procedure. 13.South Carolina law requires the prominent display of the Internet website address which contains an up-to-date list of the names and addresses of providers with which a DMPO has contracted directly or through a provider network on all advertising, marketing material, brochures and discount medical plan cards. What is that website address? FORMTEXT       14. If any of the websites are password protected or for customers-only, please provide codes to the Department to enable a full review of the site(s). 15. Provide copies of all application forms used by the DMPO and its marketers/sub-marketers, including private label brands, to sign up customers. It is important FOR you to verify that all FORMs meet the requirements of S.C. Code Section 37-17-10 et. seq. before submitting THEM with your application. 16. Provide copies of all the discount cards issued by the DMPO and its marketers/sub-marketers, including private label brands. 17. Attach a copy of the notice, included in membership agreements and marketing materials, that each customer receives stating the terms under which the discount medical plan may be returned or cancelled. 18. Attach a list of all additions and subtractions to your previously filed list of providers or provider networks with whom your DMPO has contracts or agreements to provide discounted health care services to South Carolina customers. 19. Attach copies of the form of all current contracts made or to be made between the applicant and any providers or provider networks regarding the provision of medical services to South Carolina customers. 20. Attach a detailed description of the customer complaint procedures to be established and maintained by the DMPO and its marketers/sub-marketers, including private label brands. MARKETERS 1. Provide a list of all of the Applicants authorized marketers, as defined in S.C. Code Ann. 37-17-20 (5), including any sub-marketers and private label brands. 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Box 5757 Columbia, SC 29250-5757 Do not fax this form. An original, signed and notarized form is required. The South Carolina Freedom of Information Act may require the S.C. Department of Consumer Affairs to release this form as a public record; however personal identifying information will be released only if required by law. DMPO Renewal Application SCDCA Form DMPO-02 Revised 11/07 Page  PAGE 1 of  NUMPAGES 10 Street Address 3600 Forest Drive Columbia, SC 29204-4006 Mailing Address P.O. 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