1. (a) On or before May 15th of each year, each licensed plan shall file a report in the following form and containing the information specified therein:

   State of California

   Dept. of Managed Care

   Department of Managed Care

   File Number

   REPORT OF ENROLLMENT IN PLAN

   Knox-Keene Health Care Service Plan Act

2. 1. Name of Plan:

3. 2. Name, mailing address, and telephone number of Plan official to whom communications concerning this report should be addressed:

   ( )

   Name

   Phone No.--Include area code

   Mailing Address

   City, State and ZIP Code

4. 3. For the purposes of Section 1356(b) of the Knox-Keene Health Care Service Plan Act, the Plan reports that, as of March 31 of the year in which this report is made, its records reflected the following enrollments, in accordance with the definitions contained in Section 1345, Health and Safety Code:

   Number of subscribers

   Number of enrollees

   (Note: As required by Section 1356(b), if the number of enrollees is estimated, the method used for determining the estimated enrollment must be disclosed.)

5. 4. Execution: I certify under penalty of perjury that the above statement is true.

   Executed at________________________________________(City and State) on ____________________(Date)

   Signature

   Print or Type Name of Declarant

   Position with Plan

Note: Authority cited: Section 1344, Health and Safety Code. Reference: Sections 1356, 1384 and 1385, Health and Safety Code.

History

1. New section filed 5-9-80; effective thirtieth day thereafter (Register 80, No. 19).

2. Change without regulatory effect amending section filed 1-23-91 pursuant to section 100, title 1, California Code of Regulations (Register 92, No. 10).

3. Change without regulatory effect amending subsection (a) filed 7-18-2000 pursuant to section 100, title 1, California Code of Regulations (Register 2000, No. 29).