New Hampshire Insurance Department - For Companies, Licensing Approvals for Prospective Companies, HMO Application

skip navigation

	Home
	About Us
	For Companies
		Premium Tax
		Surplus Lines
	For Consumers
	Life, Accident & Health
	Property & Casualty
	For Producers/ Adjusters
	Media Room
	Legal Information
	Reports
	Links
	Contact Us
	Site Map

For Companies > Licensing and Approvals for Prospective Companies > Applications > HMO

Application for Insurance Companies Applying for Health Maintenance Organization Line of Business

RSA 420-B and Ins 2200 contain information for Health Maintenance Organizations (HMO). The following items are required to do business in this state as an HMO:

$1,000.00 application fee (make check payable to Treasurer, State of New Hampshire). Fee is non-refundable.
UCAA Application
Power of Attorney Form
The Company’s latest three Annual Statements
The Company’s latest examination report
By-Laws and Articles of Incorporation

Please note that if the company is applying for a regular Certificate of Authority along with an HMO Certificate of Authority, that the company may not use the same name for both licenses.

Please mail all the requested information to the New Hampshire Insurance Department Financial Examination and Analysis Division.

Adobe Acrobat Reader format. You can download a free reader from Adobe.

New Hampshire Insurance Department | 21 South Fruit Street, Suite 14 | Concord, NH 03301
Phone 603.271.2261 | Fax 603.271.1406 | Consumer Hotline 1.800.852.3416