A. An application for a certificate of authority to operate as a prepaid dental plan organization shall be filed with the Commissioner in a form prescribed by the Commissioner. The application shall be verified by an officer or authorized representative of the applicant, and shall set forth or be accompanied by: 1. A copy of any basic organizational document of the applicant such as the articles of incorporation, articles of association, partnership agreement, trust agreement, or other applicable documents, with all amendments to such documents; 2. A copy of any bylaws, rules or regulations, or similar documents regulating the conduct of the internal affairs of the applicant; 3. A list of the names, addresses, and official positions of the persons who are responsible for the conduct of the business affairs of the applicant, including all members of the board of directors, board of trustees, executive committee or other governing board or committee, and the principal officers in the case of a corporation, and the partners or members in the case of a partnership or association; 4. A copy of any contract made or to be made between any providers of dental services or persons listed in paragraph 3 of this subsection and the applicant; 5. A statement generally describing the prepaid dental plan organization, all prepaid dental plans offered by said organizations, and facilities, and personnel; 6. A copy of the form of individual or group membership coverage or a copy of the contract to be issued to the members; 7. Financial statements showing assets, liabilities, and sources of financial support of the applicant. If the financial affairs of the applicant are audited by independent certified public accountants, a copy of the most recent regular certified financial statement for the applicant shall satisfy this requirement unless the Commissioner determines that additional or more recent financial information is required; 8. A description of the proposed method of marketing the prepaid dental plan, a financial prospectus which includes a three- year projection of the initial operating results anticipated, and a statement as to the sources of working capital available for the operation of the prepaid dental plan as well as any other sources of funding; 9. A power of attorney, duly executed by said applicant if not domiciled in this state appointing the Commissioner, as the true and lawful representative for service of process for said applicant in this state, upon whom all lawful process in any legal action or proceeding against the prepaid dental plan organization on a cause of action arising in this state may be served; 10. A fee of One Hundred Dollars ($100.00) for issuance of a certificate of authority; and 11. Such other information as the Commissioner may require. B. Within ten (10) days following any said modification of information previously furnished as required by subsection A of this section, a prepaid dental plan organization shall file notice of said modification with the Commissioner.
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