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Form GSI-105-2
Otherwise, this Certificate is valid for a maximum of one year from the date certified by the group self-insurer. GSI-105.2 (2-02). 3. Name and Address of Group
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An application fee of five dollars ($5) per vehicle is required for vehicles being registered under this Application for. Certificate of Self-Insurance. A
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Provider Contract Guidelines for Article 44 MCOs, IPAs, and
Apr 1, 2017 Managed Long Term care plans (MLTC) certified pursuant to NYS PHL 4403-f. New York State Department of Health Standard Clauses for Managed Care.
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