Discount Medical Plan Organization (DMPO) Renewal Form
For the renewal period May 1, 2016 to April 30, 2017
Name of Discount Medical Plan Organization: _______________________________________________
DMPO’s Principal Office Address: ________________________________________________________
DMPO’s Web Site(s): __________________________________________________________________
Nebraska Company Code: _ _ _ _ _ _
FEIN: _ _ - _ _ _ _ _ _ _
$300 renewal fee made payable to the Nebraska Department of Insurance
Submit this renewal form to the Nebraska Department of Insurance no later than March 1, 2016. The
renewal form must include the $300 renewal fee and must be certified as true and complete by a corporate
officer, partner, owner, or other duly authorized member of the DMPO. If the response to any question
below is “yes”, please provide details and attach the required explanation or documentation to this form.
Number of DMPO members in Nebraska?
Has the DMPO received any complaints from members or providers in the past year? If yes,
please provide a complaint log stating each complainant’s name, date and nature of complaint,
and resolution including the basis for any denial of benefits. The complaint log should be
signed by the DMPO’s compliance officer.
Has there been any change to the list of names and address of the persons responsible for the
conduct of the DMPO’s affairs (to include a compliance officer) including disclosures of the
extent and nature of any contracts or arrangements with such persons and the DMPO,
including any conflicts of interest, since the DMPO last provided this information?
Have any of the persons responsible for conduct of the DMPO’s affairs, including all
corporate officers, been charged with or convicted of a crime? “Crime” includes a
misdemeanor, felony or military offense. If yes, provide a certified copy of the charging
document and any resolution of the charges, with a written explanation of the circumstances.
Have the DMPO and/or affiliates had an application for registration or licensure denied or a
certificate of registration or license revoked, suspended, or terminated?
Has the DMPO and/or persons responsible for conduct of the DMPO been sued by any entity
in any jurisdiction in the past five years, or has the DMPO and/or affiliates been investigated
for or found in violation of any statute or regulation?
Was the DMPO at any time unable to fully pay when due any debts or other obligations?
Has the listing of health care providers currently under contract changed?
I hereby certify that the information contained in this annual report and attachments is true and complete.
Name and Title