(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 __________,_____.
Notary Public _______________________________
My commission expires ___________________
