state of Wisconsin
By
Name of Registrant
On behalf of 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:
ITEM 1. IDENTITY OF PARTIES TO TRANSACTION
Furnish the following information for each of the parties to the transaction covered under s.
648.45, Stats., and s.
Ins 57.12 (2), Wis. Adm. Code:
(a) Name;
(b) Home office address;
(c) Principal executive office address;
(d) The organizational structure, i.e., corporation, partnership, individual, trust, etc.;
(e) A description of the nature of the parties' business operations;
(f) Relationship, if any, of other parties to the transaction to the care management organization filing the notice, including any ownership or debtor/creditor interest by any other parties to the transaction in the care management organization seeking approval, or by the care management organization filing the notice for the affiliates;
(g) Where the transaction is with a non–affiliate, the name(s) of the affiliate(s) which will receive, in whole or in substantial part, the proceeds of the transaction.
ITEM 2. DESCRIPTION OF THE TRANSACTION
Furnish the following information for each transaction for which notice is being given:
(b) A statement of the nature of the transaction; and
(c) The proposed effective date of the transaction.
ITEM 3. SALES, PURCHASES, EXCHANGES, LOANS, EXTENSIONS OF CREDIT, GUARANTEES OR INVESTMENTS
Furnish a brief description of the amount and source of funds, securities, property or other consideration for the sale, purchase, exchange, loan, extension of credit, guarantee, or investment. Describe any provision for purchase of the care management organization filing notice, by any party to the transaction, or by any affiliate of the care management organization filing notice. Give a description of the terms of any securities being received, if any, and a description of any other agreements relating to the transaction such as contracts or agreements for services, consulting agreements and the like. If the transaction involves consideration other than cash, furnish a description of the consideration, its cost and its fair market value, together with an explanation of the basis for evaluation.
If the transaction involves a loan, extension of credit or a guarantee, furnish a description of the maximum amount which the care management organization will be obligated to make available under such loan, extension of credit or guarantee, the date on which the credit or guarantee will terminate, and any provisions for the accrual of or deferral of interest.
If the transaction involves an investment, guarantee or other arrangement, state the time period during which the investment, guarantee or other arrangement will remain in effect, together with any provisions for extensions or renewals of such investments, guarantees or arrangements. Furnish a brief statement as to the effect of the transaction upon the care management organization's net assets.
No notice need be given if the maximum amount which can at any time be outstanding or for which the care management organization can be legally obligated under the loan, extension of credit or guarantee is less than (a) in the case of nonlife care management organizations, the lesser of 2% of the care management organization's assets or (b) 10% of net assets as of December 31 of the immediately preceding calendar year.
ITEM 4. LOANS, EXTENSIONS OF CREDIT, OR GUARANTEES TO OR FOR A NONAFFILIATE
If the transaction involves a loan, extension of credit, or guarantee to any person who is not an affiliate, furnish a brief description of the agreement or understanding whereby the proceeds of the proposed transaction, in whole or in substantial part, are to be used to make loans or extensions of credit to, to purchase the assets of, or to make investments in, any affiliate of the care management organization making such loans, extensions of credit, or guarantee. Specify in what manner the proceeds are to be used to loan to, extend credit to, purchase assets of or make investments in any affiliate. Describe the amount and source of funds, securities, property or other consideration for the loan or extension of credit and, if the transaction is one involving consideration other than cash, describe its cost and its fair market value together with an explanation of the basis for evaluation. Furnish a brief statement as to the effect of the transaction upon the care management organization's net assets.
No notice need be given if the loan or extension of credit is one which equals less than the lesser of 2% of the care management organization's assets or 10% of net assets as of December 31 of the immediately preceding calendar year.
ITEM 5. MANAGEMENT AGREEMENTS, SERVICE AGREEMENTS AND COST–SHARING ARRANGEMENTS
For management and service agreements, furnish:
(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:
