KRS 304.17A-808: Application for certificate of filing -- Fee.

A proposed self -insured employer -organized association group shall file with the

commissioner an application for a certificate of filing accompanied by a nonrefundable

filing fee of five hundred dollars ($500). Each application for a certificate of filing shall

be submitted to the commissioner upon a form prescribed by the commissioner and shall

set forth or be accompanied by:

(1) The group's name, location of its principal office, date of organization, and

identification of its fiscal year. The application shall also include the name and

address of each member if known at the time of application. If this information is

unknown, a description of the group to be solicited for membership shall be

included;

(2) A copy of the articles of association or governance documents;

(3) A copy of agreements with the administrator and with any service company;

(4) A copy of the bylaws of the proposed group;

(5) Certification of the group's financial solvency as set forth in KRS 304.17A-812;

(6) Designation of the initial board of trustees and administrator;

(7) The address where books and records of the group will be maintained at all times;

and

(8) A statement describing the self -insured employer-organized association which shall

include:

(a) The health services to be offered;

(b) The financial risks to be assumed;

(c) The initial geographic area to be served;

(d) Pro forma financial projections for the first three (3) years of operation,

including the assumptions the projections are based upon;

(e) The sources of working capital and funding;

(f) A description of the persons to be covered by the self -insured employer -

organized association;

(g) Any proposed reinsurance arrangements;

(h) Any proposed management, administrative, or cost-sharing arrangements; and

(i) A description of the self -insured employer-organized association's proposed

method of marketing.