WEST VIRGINIA

							        STATE OF WEST VIRGINIA
        Offices of the Insurance Commissioner
        Financial Conditions Division
 Mailing Address:                                     Telephone 304.558.2100                       Location:
 Financial Conditions                                 Facsimile 304.558.1365                       Financial Conditions
 PO Box 50540                                  financial.conditions@wvinsurance.gov                1124 Smith Street, Room 102
 Charleston WV 25305-0540                              www.wvinsurance.gov                         Charleston WV 25301


                            DISCOUNT MEDICAL PLAN ORGANIZATION (“DMPO”)

W. Va. Code §33-15E and W.V.C.S.R 114-83. A Discount Medical Plan Organization means an entity that contracts with
providers, provider networks or other discount medical plan organizations to offer access to medical or ancillary services at
a discount to plan members, provides access for discount medical plan members to the services in exchange for fees, dues,
charges or other consideration, and determines the charges to plan members.

                                                     Filing Requirements

The following must be submitted in its entirety to be approved by the Insurance Commissioner in order to become
registered to act as a Discount Medical Plan Organization in the State of West Virginia:

1.    A fully completed Discount Medical Plan Organization Application (Form DMP-1 (see below)).
2.    A $300 non-refundable application fee. (Subject to reciprocity). The annual renewal fee is $100.
3.    An original Certificate of Authority from the state of domicile, if applicable.
4.    Copies of all registration documents and/or licenses required by the State of West Virginia.
5.    Articles of Incorporation and By-Laws, if applicable.
6.    A description of the proposed method of marketing, including types of discounts to be offered and the advertising
      media to be used, including the procedures in place to approve advertising, prior to use pursuant to W. Va. Code §33-
      15E-11.
7.    Audited Financial Statements prepared in accordance with generally accepted accounting principals certified by an
      independent certified public accountant, including the balance sheet, income statement and statement of changes in
      cash flow for the preceding year or if an affiliate of a parent entity that is publicly traded, those audited financial
      statements and a written guarantee that the minimum capital will be met by the parent entity. (Also required for
      annual renewal)
8.    A list of names and the official positions and addresses of all persons responsible for the conduct of the organizations
      affairs, including company officers, directors, and shareholders owning ten percent or more shares in the organization.
      (Also required for annual renewal)
9.    The number of discount medical plan members in the state. (Also required for annual renewal)
10.   A copy of the form of all written provider agreements offering medical or ancillary services to its members.
11.   A list of all participating pharmacies offering discounts on prescription drugs to plans members or an Internet website
      address where such a list can be accessed by the Commissioner. (Also required for annual renewal)
12.   Organization chart including all entities within the ultimate parent company structure, if applicable.
13.   Biographical Affidavits for company officers, directors, and shareholders (including entities) owning 10% or more of
      applicant.
14.   Proof of maintenance with the net worth requirement of $150,000 pursuant to W. Va. Code §33-15E-5. (Also
      required for annual renewal)
15.   A fully completed Discount Medical Plan Organization Surety Bond pursuant to W. Va. Code §33-15E-6 (Form
      DMP-2).
16.   A description of the member complaint procedures to be established and maintained by the applicant.
17.   A member agreement with any accompanying literature pursuant to W.V.C.S.R 114-83-4.

                                                  Renewal of License

On or before May 31 of each year, every discount medical plan organization shall submit a complete registration
application Form DMP-1 (see below), required annual renewal filing requirement, and the applicable renewal fee of $100.


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       STATE OF WEST VIRGINIA
       Offices of the Insurance Commissioner
       Financial Conditions Division
Mailing Address:                                       Telephone 304.558.2100                             Location:
Financial Conditions                                   Facsimile 304.558.1365                             Financial Conditions
PO Box 50540                                    financial.conditions@wvinsurance.gov                      1124 Smith Street, Room 102
Charleston WV 25305-0540                                www.wvinsurance.gov                               Charleston WV 25301


                                        Registration Application (DMP-1)
Name of Applicant:

DBA (if applicable):

Home Office Address:
                               (Street or PO Box)                         City                    State            Zip Code

Mailing Address:
                               (Street or PO Box)                         City                    State            Zip Code

Contact Person:
Phone Number:              (     )                                          Fax Number:       (       )
E-mail Address:

Compliance Officer:
Address:
Phone Number:              (     )                                          Fax Number:       (       )
E-mail Address:

Type of Business Organization:
   Corporation        Limited Liability Company                           Partnership             Other. Identify/Explain:


State of Domicile:                   Formation Date:                               FEIN Number:
                                                                 Mo/Day/Year


List all states which the applicant is currently registered as a discount medical plan organization.



List all states which a discount medical plan organization application has been refused or denied.



List Names and Addresses of all Members, or Officers, or Owners of the Applicant:
      Full Name                      Title                                          Address                              % Ownership




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          STATE OF WEST VIRGINIA
          Offices of the Insurance Commissioner
          Financial Conditions Division
   Mailing Address:                                         Telephone 304.558.2100                            Location:
   Financial Conditions                                     Facsimile 304.558.1365                            Financial Conditions
   PO Box 50540                                      financial.conditions@wvinsurance.gov                     1124 Smith Street, Room 102
   Charleston WV 25305-0540                                  www.wvinsurance.gov                              Charleston WV 25301


Please read the following very carefully and answer every question. All copies of documents must be certified. All written statements
submitted by the Applicant must include an original signature.

1. Has the DMP or any owner, partner, officer or director of the business entity, or member or manager of a                  Yes         No
limited liability company, ever been convicted of, or is the business entity or any owner, partner, officer or
director, member or manager currently charged with, committing a crime, had a judgment withheld or deferred,
or are you currently charged with committing a crime? If you answer Yes, you must attach to this application:
a) a written statement explaining the circumstances of each incident,
b) a certified copy of the charging document,
c) a certified copy of the official document, which demonstrates the resolution of the charges or any final
judgment.
“Crime” includes a misdemeanor, felony or a military offense. You may exclude misdemeanor traffic citations or convictions involving
driving under the influence (DUI) or driving while intoxicated (DWI), driving without a license, reckless driving, or driving with a
suspended or revoked license and juvenile offenses. “Convicted” includes, but is not limited to, having been found guilty by verdict of a
judge or jury, having entered a plea of guilty or nolo contendre, or having been given probation, a suspended sentence or a fine.

2. Has the DMP or any owner, partner, officer or director, or manager or member of a limited liability company,               Yes        No
ever been involved in an administrative proceeding regarding any professional or occupational license, or
registration? If you answer Yes, you must attach to this application:
a) a written statement identifying the type of license and explaining the circumstances of each incident,
b) a certified copy of the Notice of Hearing or other document that states the charges and allegations, and
c) a certified copy of the official document which demonstrates the resolution of the charges or any final
judgment.
“Involved” means having a license censured, suspended, revoked, canceled, terminated; or, being assessed a fine, a cease and desist order,
a prohibition order, a compliance order, placed on probation or surrendering a license to resolve an administrative action. “Involved” also
means being named as a party to an administrative or arbitration proceeding, which is related to a professional or occupational license.
“Involved” also means having a license application denied or the act of withdrawing an application to avoid a denial. You may EXCLUDE
terminations due solely to noncompliance with continuing education requirements or failure to pay a renewal fee.

3. Has any demand been made or judgment rendered against the business entity or any owner, partner, officer or               Yes            No
director, or member or manager if a limited liability company, for overdue monies by member, or have you ever
been subject to a bankruptcy proceeding? Only include bankruptcies that involve funds held on behalf of others.
If you answer Yes, submit a statement summarizing the details of the indebtedness and arrangements for
repayment.

4. Has the business entity or any owner, partner, officer or director, or member or manager of a limited liability           Yes            No
company, ever been notified by any jurisdiction to which you are applying of any delinquent tax obligation that is
not the subject of a repayment agreement? If you answer yes, identify the jurisdiction(s).

5. Is the DMP or any owner, partner, officer or director a party to, or ever been found liable in any lawsuit or             Yes            No
arbitration proceeding involving allegations of fraud, misappropriation or conversion of funds, misrepresentation
or breach of fiduciary duty? If you answer Yes, you must attach to this application:
a) a written statement summarizing the details of each incident,
b) a certified copy of the Petition, Complaint or other document that commenced the lawsuit or arbitration, and
c) a certified copy of the official document which demonstrates the resolution of the charges or any final
judgment.

6. Has the DMP or any owner, partner, officer or director, or member or manager if a limited liability company,              Yes            No
ever had a contract or any other business relationship terminated for any alleged misconduct? If you answer Yes,
you must attach to this application:
a) a written statement summarizing the details of each incident and explaining why you feel this incident should
not prevent you from receiving an insurance license, and
b) certified copies of all relevant documents.
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                                                              Page 3 of 4
           STATE OF WEST VIRGINIA
           Offices of the Insurance Commissioner
           Financial Conditions Division
 Mailing Address:                                      Telephone 304.558.2100                           Location:
 Financial Conditions                                  Facsimile 304.558.1365                           Financial Conditions
 PO Box 50540                                   financial.conditions@wvinsurance.gov                    1124 Smith Street, Room 102
 Charleston WV 25305-0540                               www.wvinsurance.gov                             Charleston WV 25301


On behalf of the DMP, the undersigned owner, partner, officer or director of the business entity, or member or manager of a
limited liability company, hereby certifies, under penalty of perjury, that:
1. All of the information submitted in this application and attachments is true and complete and I am aware that submitting
false information or omitting pertinent or material information in connection with this application is grounds for license or
registration revocation and may subject me and the business entity or limited liability company to civil or criminal
penalties.
2. The business entity or limited liability company grants permission to the Commissioner or Director of Insurance in each
jurisdiction for which this application is made to verify any information supplied with any federal, state or local government
agency, current or former employer or insurance company.
3. Every owner, partner, officer or director of the business entity, or member or manager of a limited liability company,
either a) does not have a current child-support obligation, or b) has a child-support obligation and is currently in compliance
with that obligation.
4. I authorize the jurisdictions to give any information they may have concerning me to any federal, state or municipal
agency, or any other organization and I release the jurisdictions and any person acting on their behalf from any and all
liability of whatever nature by reason of furnishing such information.
5. I acknowledge that I understand and comply with the insurance laws and regulations of the jurisdictions to which I am
applying for licensure/registration.
6. If required, I have received a Certificate of Good Standing from the jurisdiction's Secretary of State in which I am
applying.
7. For Non-Resident Applications, I certify that I am licensed or registered and in good standing in my home state/resident
state.

Must be signed by an officer, director, or partner of the business entity, or member or manager if a limited
liability company:

                             Notarial Acknowledgement Required of all Applicants
Dated and signed this             day of _      __            , 20                at            .
_    __         _        being duly sworn according to law, deposes and says that the answers to the questions and the
declarations contained in this application are true and correct and that all of the applicable Filing Requirements contained
on Page 1 have been met.


                 Signature                           Title (Type or Print)                  Full Legal Name (Type or Print)

State of
City/County of
Personally appeared before me the above named                           personally known to me, who, being duly sworn,
deposes and says that he/she executed the above instrument and that the statements and answers contained therein are true
and correct to the best of his/her knowledge and belief.
Subscribed and sworn to before me this               day of                      , 20   .

(SEAL)                                                             _______
                                                        Notary Public
                                        My Commission Expires:
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