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					                                                  NORTH CAROLINA DEPARTMENT OF INSURANCE
                                                     LIFE AND HEALTH DIVISION CHECKLIST



COMPANY NAME:

NAIC Code (#####):

Leading Form #:


   REVIEW
REQUIREMENTS           REFERENCE                                          COMMENTS
TYPE of FILING: FRANCHISE
GENERAL INFORMATION ONLY
A franchise plan is a form of accident and health insurance that is intended to provide coverage to the "membership" of the sponsoring organziation only.
The accident and health insurance plan is an individual policy varying only as to the amounts and kinds of coverage applied for by such person. The
accident and health insurance policy form must meet the other statutory and regulatory standards applicable to the type of insurance involved. Please
refer to the specific checklist for the type of insurance for those additional requirements.


                                      A franchise plan is a form of accident and health insurance that is intended to provide
                                      coverage to the "membership" of the sponsoring organziation only. The accident and
                     NCGS 58-51-90    health insurance plan is an individual policy varying only as to the amounts and kinds
                                      of coverage applied for by such person. The premiums on such policies may be paid
                                      by the sponsoring organization or other designated party of the organization.


                                      Franchise plans are merely a different means of delivering accident and health
                                      insurance. Franchise plans must comply with all of the applicable requirements and
                     NCGS 58-51-90
                                      provisions related to the specific type of benefits provided in the plan. Refer to the
                                      benefit specific checklist for the compliance specifics for the franchise plan.

                                      The following statement should be placed on a separate jacket and put in to
                                      brackets: THIS IS A FRANCHISE INSURANCE POLICY INTENDED TO BE SOLD
                     NCGS 58-51-90
                                      TO MEMBERS OF SPONSORING EMPLOYER (ASSOCIATION) GROUPS AND
                                      THEIR FAMILY MEMBERS.




                                                                          PAGE 1
                                          NORTH CAROLINA DEPARTMENT OF INSURANCE
                                             LIFE AND HEALTH DIVISION CHECKLIST


   REVIEW
REQUIREMENTS   REFERENCE                                                COMMENTS
TYPE of FILING: FRANCHISE

                             A detailed reason or explanation as to why a requirement is not
                            applicable must be provided on a separate page for those
                            requirements referenced by N/A


                            I, the filer, acknowledge that I have prepared the submitted form(s) in
                            accordance with the checklist and to the best of my knowledge this file
                            is in substantial compliance with all of the above listed reference
                            point’s.




                            Signature of Filer


                            The Life and Health Division checklist is intended to expedite the Departments overall review time of new
                            form filings. The checklist serves as a basic guide to assist the Industry in preparation of new form
                            filings prior to submission. The checklist is not a substitute for Departmental review. All forms must
                            comply with State Insurance Law.




                                                                       PAGE 2
                                               NORTH CAROLINA DEPARTMENT OF INSURANCE
                                                  LIFE AND HEALTH DIVISION CHECKLIST



                               Rev. 11/08/07




ip" of the sponsoring organziation only.
ge applied for by such person. The
e type of insurance involved. Please




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                                                               PAGE 3
       NORTH CAROLINA DEPARTMENT OF INSURANCE
          LIFE AND HEALTH DIVISION CHECKLIST




Date




                       PAGE 4

				
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