Name of Service Contract Provider TRANSACT BUSINESS IN THE … › ... ›...

OFFICE OF SUPERINTENDENT OF INSURANCEP.O. BOX 1689

SANTA FE, NEW MEXICO 87504-1689(505) 827-4362

SUMMARY OF REQUIRED DOCUMENTS FROMSERVICE CONTRACT PROVIDERS SEEKING REGISTRATION TO

TRANSACT BUSINESS IN THE STATE OF NEW MEXICO

Name of Service Contract Provider

In support of the application, please furnish the OSI with the items listed below:

_1. APPLICATION FEE A non-refundable application fee in the sum of $500.00must accompany this application before it can be reviewed in accordance withNMSA §59A-58-5-A (4). Make the check payable to the Office ofSuperintendent of Insurance or OS/.

2. APPLICATION FOR REGISTRATION

IF A NATURAL PERSON OR PARTNERSHIP:Apply by letter stating that the individual or partnership is seeking registration totransact service contract business in the State of New Mexico and acknowledgesthat the Service Contract Company will abide by NMSA 59A-58-6 (2) (a) (b).

LF A CORPORATION:Apply by letter, transmitting a certified copy of the Resolution of the Board ofDirectors stating under oath, of the president or vice president, or other chiefofficer on behalf of the company, that the company is seeking admission as aservice contract provider company. The Resolution must be notarized.

_3. ARTICLES OF INCORPORATION If a corporation provide the company's initialArticles of Incorporation and all amendments thereto. The Articles ofIncorporation must be certified, and bear the seal of the state official havingcustody of the original documents.

_4. BY-LAWS Provide a copy of the By-Laws certified by the state official havingcustody of the original or the company's corporate secretary. Ensure that thecorporate seal is affixed to the secretary's certification.

5. CERTIFICATE OF COMPLIANCE/CERTIFICATE OF GOOD STANDINGProvide a Certificate of Compliance or Certificate of Good Standing certified bythe state of domicile.

_6. CERTIFICATE OF GOOD STANDING Provide a Certificate of Good Standingcertified by the NM Office of the Secretary of State, Corporation Division.

_7. CONTACT PROCESSING FORM Must be completed in its entirety.

Service Contract Provider(Rev. 11/18)

_8. STATEMENT Please provide us with an original notarized statement indicatingwhat the service contact will cover.

J9. ADMINISTRATOR Provide us with the name, address, and telephone numberof each administrator with whom the provider intends to contract.

10. DEPOSIT- SURETY BOND OR REIMBURSEMENT POLICY

1. A surety bond issued by a surety company authorized to do business inNew Mexico on a form acceptable to the superintendent. Securities of thetype eligible for deposit by an insurance company in the amount of$50,000.00 or $100,000.00 is required to be made with the Office ofSuperintendent in accordance with NMSA Section 59A-58-6 uponapproval of the company for registration to transact business in NewMexico. Pursuant to NMSA Section, 59A-58-6(B) the deposit amount isbased on what the service contract covers. Please provide the originalSurety Bond and three original (three original signatures) Deposit Form600, which can be found athttp://www.osi.state.nm.us/CompanvLicensina/statutorvdeposits.aspx

2. Obtain a reimbursement insurance policy pursuant to NMSA Section 59A-58-6(A) (2). Please provide us with the reimbursement insurance policyfor review and approval.

Please mail the application fee along with items 1 through 10 in paper form to:

Office of Superintendent of Insurance (OSI)Attn: Company Licensing Bureau1120 Paseo De Peralta, Room 439

Santa Fe, New Mexico 87501

If you have any questions regarding the requested documents above, please contactthe Company Licensing Bureau at 505-827-4362.

Service Contract Provider(Rev. 11/18)

OFFICE OF SUPERINTENDENT OF INSURANCECOMPANY LICENSING BUREAUP. 0. BOX 1689SANTA FE, NEW MEXICO 87504-1689(505) 827-4362

PLEASE READ BEFORE COMPLETING:

-PLEASE TYPE OR PRINT NEATLY

-COMPLETE ENTIRE FORM-DO NOT LEAVE ANY BLANKS

-CONTACT PERSON & PHONE NUMBER-MUST BELOCATED AT ADDRESS INDICATED

SERVICE CONTRACT PROVIDER CONTACT PROCESSING FORM

COMPANY COMPLETE NAME - Do not abbreviate name.

COMPANY HOME ADDRESSPhysical location only:

City:

Contact Person:

- MUST BE LOCATED

State:

Email

IN STATE OF DOMICILE

Address:

Zip Code:

Phone Number:

COMPANY MAILING ADDRESSStreet, P 0 Box, etc.:

City:

Contact Person:

State:

Email Address:

Zip Code:

Phone Number:

COMPANY CONTACT FOR SURETY BONDS OR REIMBURSEMENT INSURANCE POLICYStreet, PO Box, etc.:

City:

Contact Person:

State:

Email Address:

Zip Code:

Phone Number:

COMPANY CONTACT FOR REGULATORY MATTERSStreet, PO Box, etc.:

City:

Contact Person:

State:

Email Address:

Zip Code:

Phone Number:

COMPANY CONTACT FOR AGENT FOR SERVICE OF PROCESSStreet, PO Box, etc.:

City:

Contact Person:

State:

Email Address:

Zip Code:

Phone Number:

Revised 07/17