THE APPLICABLE LIMITS OF LIABILITY AND ARE SUBJECT TO THE RETENTIONS 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin with the 'Organizational Information' section. Fill in your Applicant Name, Years in Business, Principal Address, and Primary Business Activity. Ensure all fields are completed accurately.
3. Proceed to the compliance-related questions. Answer whether there have been any changes to your Medical Billings or Chief Compliance Officer, and provide details if applicable.
4. In the 'Billing Procedures' section, specify who performs government-funded healthcare program billing and indicate if any billing is done by a third party. Include relevant percentages and names as required.
5. Complete the 'Coverage Information' section by detailing current limits, retentions, and premiums. Make sure to check for any specific instructions related to your state.
6. Finally, review all sections for completeness before signing. Ensure that all necessary attachments are included as specified in the application.

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