Applications

(ie. service contracts, extended warranty, pre-paid legal).
 
Consumer Guaranty Contracts are subject to New Hampshire Revised Statutes Annotated RSA 415-C. Each registrant is responsible to review and understand the law before completing an application form.

• Application for new entities 
• Surety bond 

Send all required items to the New Hampshire Insurance Department, Financial Regulation Division.

If you have any questions, please contact ConsumerGaurantyContracts@ins.nh.gov.

Please review RSA 415:I, Discount Medical Plan Organization's current statute, for information and guidance in properly completing application for registration.

Entities that register December 2008 through May 2009 will not need to register again until June 2010.

The following are filing requirements to register as a Discount Medical Plan Organization:

• Application form (NEED DOC)
• $300 application fee (non-refundable), make check payable to: Treasurer, State of New Hampshire.

Send the application to the attention of New Hampshire Insurance Department, Financial Regulation Division.

The New Hampshire Insurance Department will notify you when all items necessary are received and the Organization is placed on the approved Discount Medical Plan Organization list.

If you have any questions, please contact Linda M. Zalinskie.

Please review RSA 402-E, Managing General Agent’s current statute, for information and guidance in properly completing the application and applying for a license.

The following are filing requirements to apply for a Managing General Agent’s license:

• Application form 
• $50.00 application fee (non-refundable), make check payable to: Treasurer, State of New Hampshire
• $350.00 original license fee(non-refundable)
• Copy of the current producer license from the State of Incorporation
• Copy of the current producer license from New Hampshire
• The MGA must have a written contract between the parties before placing business with an insurer. A copy of the contract must be submitted as soon as available to the address below. (RSA 402-E:3)

The application process will commence upon the receipt of the above requested information and appropriate application fee. Send all items listed above to the New Hampshire Insurance Department Financial Regulation Division. Licensing fees will be requested upon approval.

If you have any questions, please contact Linda M. Zalinskie.

Please review RSA 405-A for New Hampshire’s state statute regarding purchasing groups.

The following are filing requirements to apply for approval as a Purchasing Group:

• Application 
• Letter from the New Hampshire Insurance Commissioner regarding Purchasing Groups .

Send the application to the attention of New Hampshire Insurance Department, Financial Regulation Division.

The New Hampshire Insurance Department will notify you when all items necessary are received and the purchasing group is placed on the approved purchasing group list.

If you have any questions, please contact Linda M. Zalinskie.

Please review RSA 405-A for New Hampshire’s state statutes regarding Risk Retention Groups.

The following items are necessary to send when applying to be an approved Risk Retention Group in New Hampshire:

• Application  
• Current Annual Statement and quarterly statements
• CPA report
• Actuarial Opinion
• MD & A
• Exam Report

Risk Retention Groups are required to send in all documents that are on our check list for Property & Casualty Companies. The tax forms are also available on the Web.

Please notify us of any changes and continue to update with all forms requested on the check list.

Send the application to the New Hampshire Insurance Department, Financial Regulation Division.

The New Hampshire Insurance Department will notify you when all items necessary are received and the Risk Retention Group is placed on our approved list.

If you have any questions, please e-mail Linda M. Zalinskie.

Please review RSA 402-F, Reinsurance Intermediaries current statute, for information and guidance in properly completing the application and applying for a license.

The following are filing requirements to apply for a Reinsurance Intermediary license:

• Application form 
• $50.00 application fee (Non-refundable), make check payable to: Treasurer, State of New Hampshire.
• $350.00 original license fee (Non-refundable)
• Copy of the current producer license from the state of Incorporation.
• Copy of the current producer license from New Hampshire.
• The Reinsurance Intermediary must have a written contract between the parties before placing business with an insurer. A copy of the contract must be submitted as soon as available to the address below. (RSA 402-F:3)

The application process will commence upon the receipt of the above requested information and appropriate application fee. Licensing fees will be requested upon approval. Send all documents listed above to the New Hampshire Insurance Department, Financial Regulation Division.

If you have any questions, please contact Linda M. Zalinskie.

The following items need to be submitted to the address below to be considered for a Third Party Administrator License:

Please review RSA 402-H and Ins 2300.

• Application Form 
• Surety Bond Form  
• NAIC Biographical Affidavit Form 
• $1,000.00 application fee. **Fee is non-refundable.
• A detailed written business plan describing the planned or expected business activity in New Hampshire must also be included.
• State the name(s) of the owner(s) of the administrator.

The completed application package and filing fee should be directed to the New Hampshire Insurance Department, Financial Regulation Division.

Please note that effective October 1, 1995, the New Hampshire Department of Labor assumed sole responsibility, regulatory authority and licensing for Third Party Administrators for Self-Insured Workers’ Compensation, pursuant to 1995 Chapter 161. The Insurance Department will continue to regulate all other Third Party Administrators. It is possible that your company may be required to be licensed by both the Department of Insurance and the Department of Labor. To contact the New Hampshire Department of Labor, call (603) 271-3176.

If you have any questions, please contact Linda M. Zalinskie.

The following items need to be submitted to the address below to be considered for a Third Party Administrator Exception or Exemption:

Please review RSA 402-H and Ins 2300.

The Exemption application has been modified to reflect changes in the law. There are now two different applications - Exemption Application and Exception Application. Please review both applications and submit only one application depending on which item the entity qualifies for.

• Exemption Application 
• Exception Application  
• A written business plan describing the planned or expected business activity in New Hampshire must also be included.
• State the name(s) of the owner(s) of the administrator.

The completed application package should be directed to the New Hampshire Insurance Department, Financial Regulation Division.

If you have any questions, please contact Linda M. Zalinskie.

The following are the filing requirements to become licensed as a Medical Utilization Review Entity:

• Application form  
• $500.00 application fee (Ins 2001.10). Please make check payable to "Treasurer, State of New Hampshire." The fee is non-refundable.
• The entity must have URAC (Utilization Review Accreditation Commission) approval or NCQA (National Committee for Quality Assurance) approval per RSA 420-E:3.
• The entity must have a Medical Director licensed in New Hampshire. Contact the Board of Medicine for application at (603) 271-1203.

Please also review:

• NHCAR Part Ins 2000 - Medical Utilization Review Entities.
• RSA 420-E - Licensure of Medical Review Entities.
• RSA 420-J - Managed Care Law.

Send the application to the New Hampshire Insurance Department, Financial Regulation Division.

If you have any questions, please contact Linda M. Zalinskie.

The following items need to be submitted to the address below to be considered for a Purchasing Alliance License:

Please review RSA 420-M.

• Application Form  
• NAIC Biographical Affidavit Form (NEED DOC)
• $1,000.00 application fee. **Fee is non-refundable.

The completed application package and filing fee should be directed to the New Hampshire Insurance Department, Financial Regulation Division.

If you have any questions, please contact Linda M. Zalinskie.

The following items need to be submitted to the address below to be considered for a Multiple-Employer Welfare Arrangement Approval:

Please review RSA 415-E.

• Application Form 
• Instructions for obtaining security deposit
• Surety Bond Form 

The completed application package should be sent to the New Hampshire Insurance Department, Financial Regulation Division.

If you have any questions, please contact Colin Wilkins

Motor Vehicle Road Service, Tourist Service and Repairs - Renewal Application
 
Motor Vehicle Club renewal applications are subject to New Hampshire Revised Statutes Annotated RSA 407-C. Each registrant is responsible to review and understand the law before completing an application form.

The following are filing requirements to renew a Motor Vehicle Club license:

• Renewal Application 
• $100 application fee (non-refundable), make check payable to: Treasurer, State of New Hampshire
• Most recent audited financial statement
• Updated documents originally submitted with new application (if applicable)
• The entity must maintain capital and surplus of at least $250,000
• Send all required items to the New Hampshire Insurance Department, Financial Regulation Division.

If you have any questions, please contact Linda M. Zalinskie.