Form Ins-Murl - Application For License As A Medical Utilization Review Entity - Insurance Department - New Hampshire Page 2
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56.
The applicant is a (check one):
Sole Proprietorship
Partnership
Corporation
Other (please specify)
a.
If the applicant is a corporation, please specify the State of
incorporation:
b.
List all states in which the corporation does business:
7.
List the principal proprietors, partners, directors, officers and
administrators. Also, include any others responsible for the operation,
management and control of the applicant. Attach a separate sheet of
paper, if necessary.
Name(s)
Title(s)
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