Information Statement - Idaho Department Of Insurance
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1
2State of Idaho
DEPARTMENT OF INSURANCE
DEAN L. CAMERON
C.L. “BUTCH” OTTER
700 West State Street
Governor
Boise, Idaho
83720
Director
Phone (208)334-4250
FAX # (208)334-4398
INFORMATION STATEMENT
(Must be Typed)
1.
Chartered Name of the Self-Funded Health Care Plan:
____________________________________________________________________________
2.
Name Plan will be using in this state (if different from above):
____________________________________________________________________________
3.
Physical Address:
Street: ______________________________________________________________________
City: ____________________________________ State: __________ Zip: ______________
4.
Administrative Office Contact and Mailing Address:
General Contact and Title: ____________________________________________________
Street or P.O.: _______________________________________________________________
City: ____________________________________ State: __________ Zip: ______________
Phone: ___________________________________ FAX: ____________________________
Toll-Free Telephone Number: _________________E-mail address______________________
5.
Annual Statement Filings Contact and Mailing Address:
Contact and Title: ____________________________________________________________
Street or P.O.: _______________________________________________________________
City: ____________________________________ State: __________ Zip: ______________
Phone: ___________________________________ FAX: ____________________________
Toll-Free Telephone Number: _________________E-mail address______________________
6.
Consumer/Government Relations Contact and Mailing Address
Contact and Title: ____________________________________________________________
Street or P.O.: _______________________________________________________________
City: ____________________________________ State: __________ Zip: ______________
Phone: ___________________________________ FAX: ____________________________
Toll-Free Telephone Number: _________________E-mail address______________________
Adm-selffundinfo (6/2013)
Equal Opportunity Employer
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