Arizona § 20-1003 - Application for certificate of authority

§ 20-1003. Application for certificate of authority

A. An application for a certificate of authority to operate as a prepaid dental plan organization shall be filed with the director in a form prescribed by the director, shall be verified by an officer or authorized representative of the applicant and shall set forth, or be accompanied by, the following:

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 and all amendments to the documents.

2. A copy of any bylaws, rules and regulations or similar document 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 affairs of the applicant, including all members of the board of directors, board of trustees, executive committee or other governing board or committee, the principal officers in the case of a corporation and the partners of members in the case of a partnership or association.

4. If the prepaid dental plan organization is a corporation, evidence that the board of directors of the corporation includes:

(a) Dentists who are duly licensed pursuant to title 32, chapter 11 and who have contracted with the corporation to render dental service to members.

(b) Members of the prepaid dental plan, who shall comprise at least one-third of the members of the board.

5. A copy of any contract made or to be made between any providers or persons listed in paragraph 3 and the applicant.

6. A statement generally describing the prepaid dental plan organization and its dental plan or plans, facilities and personnel, as approved by the director.

7. A copy of the form of membership coverage that is to be issued to the members.

8. A copy of the form of any group contract that is to be issued to employers, unions, trustees or other applicants.

9. Financial statements showing the applicant's assets, liabilities and sources of financial support. If the applicant's financial affairs are audited by independent certified public accountants, a copy of the applicant's most recent regular certified financial statement shall satisfy this requirement unless the director determines that additional or more recent financial information is required for the proper administration of this article.

10. A description of the proposed method of marketing the plan, a financial plan that includes a three-year projection of the initial operating results anticipated and a statement as to the sources of working capital as well as any other sources of funding.

11. A power of attorney duly executed by the applicant, if not domiciled in this state, appointing the director, the director's successors in office and duly authorized deputies as the true and lawful attorney of the applicant in and for this state, on 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.

12. A statement reasonably describing the geographic area or areas to be served, as approved by the director.

13. The fee prescribed in section 20-167 for issuance of a certificate of authority.

14. Any other information the director may require.

B. Within ten days after any significant modification of information previously furnished pursuant to subsection A of this section, a prepaid dental plan organization shall file notice of that modification with the director.