(a) A brief description of the managerial responsibilities, or services to be performed;
(b) A brief description of the agreement, including a statement of its duration, together with brief descriptions of the basis for compensation and the terms under which payment or compensation is to be made.
For cost–sharing arrangements, furnish:
(a) A brief description of the purpose of the agreement;
(b) A description of the period of time during which the agreement is to be in effect;
(c) A brief description of each party's expenses or costs covered by the agreement;
(d) A brief description of the accounting basis to be used in calculating each party's costs under the agreement.
ITEM 6. TRANSACTIONS NOT IN THE ORDINARY COURSE OF BUSINESS
Provide a brief but complete description of any transaction not in the ordinary course of business.
ITEM 7. OTHER TRANSACTIONS REPORTABLE UNDER AN ORDER
Provide a brief but complete description of any transaction reportable under an order.
ITEM 8. SIGNATURE AND CERTIFICATION
Signature and certification required as follows:
SIGNATURE
Pursuant to the requirements of ch.
Ins 57, Wis. Adm. Code,
has caused this notice to be duly signed on its behalf in the city of
and state of
on the
day of
,
.
(SEAL)
(Name of Registrant)
BY
(Name and Title)
Attest:
(Signature of Officer)
(Title)
The undersigned deposes and says that (s)he has duly executed the attached notice dated , , for and on behalf of ; and that (s)he is the ___________
(Name of Registrant) (Title of Officer)
and that (s)he is authorized to execute and file such instrument. Deponent further says that (s)he is familiar with such instrument and the contents thereof, and that the facts therein set forth are true to the best of his/her knowledge, information and belief.
(Signature)
(Type or print name beneath)
Subscribed and sworn to this
day of , .
Notary Public _______________________________
My commission expires
FORM C
CONSENT TO JURISDICTION STATEMENT
Filed with the office of the commissioner of insurance,
state of Wisconsin
BY
(Name of Affiliate)
On Behalf of the Following Care Management Organizations
Name Address
Date: , .
Name, Title, Address and Telephone Number of Individual to Whom Notices and Correspondence Concerning this Statement Should be Addressed:
CONSENT TO JURISDICTION
The, (I), , an affiliate of ________________,
(Affiliate) (Care Management Organization)
a care management organization permitted to do business in the state of Wisconsin, pursuant to the requirements of ch.
648, Stats., do hereby consent to the jurisdiction of the Commissioner of Insurance and the courts of the state of Wisconsin.
SIGNATURE
has caused this statement to be duly signed on
(Name of Affiliate)
its behalf in the city of and state of
on the day of , .
(Name of Affiliate)
(SEAL)
BY
(Name)
(Title)
Attest:
(Signature of Officer)
(Title)
CERTIFICATION
The undersigned deposes and says that (s)he has duly executed the attached statement dated , , for and on behalf of that (s)he is the
(Name of Registrant)
_____________ of such company, and that (s)he is authorized
(Title of Officer)
to execute and file such instrument. Deponent further says that (s)he is familiar with such instrument and the contents thereof, and that the facts therein set forth are true to the best of his or her knowledge and belief.
(Signature)
(Type or print name beneath)
Subscribed and sworn to this
day of , .
