Form Ins-Murl - Application For License As A Medical Utilization Review Entity - Insurance Department - New Hampshire

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Received
Approved
License No.
Issued
STATE OF NEW HAMPSHIRE
INSURANCE DEPARTMENT
APPLICATION FOR LICENSE AS A MEDICAL UTILIZATION REVIEW ENTITY
Application is hereby made on behalf of the medical utilization review entity
herein named for a license authorizing it to transact business and to otherwise
perform as a medical utilization review entity in New Hampshire.
1.
The EXACT name of the medical utilization review entity is:
(If the name is not in English, state it and give an exact literal translation.)
2.
The medical utilization review entity’s Federal ID number or Social
Security number is:
3.
This application is for (check one):
A new license.
Renewal of an existing license.
4.
The applicant’s current street address is:
5.
The applicant’s current mailing address is:
Form INS-MURL-App-1

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