1. 1. Name of Licensee (as appearing in license)

2. 2. Person to be contacted regarding this application.

   Name

   Address

   Telephone Number

3. 3. Reason for Surrender of License (explain briefly):

4. 4. Date upon which licensee proposes to terminate business:

   If the date is subject to contingencies or will be determined hereafter, explain briefly below:

5. 5. Complete the following:
6. a. Attach a copy of the balance sheet and a statement of income and expense for the plan, prepared as of a date within 30 days of the filing of this application. Such financial statements need not be certified.
7. b. State whether the licensee is required to file certain reports pursuant to Section 1384 of the Knox-Keene Health Care Service Plan Act of 1975. If so, state the date by which the licensee will forward such reports to the Director:

8. c. Section 1300.85.1. of the rules pursuant to the Knox-Keene Health Care Service Plan Act of 1975 requires that the books and records of a plan be preserved for a period of five years. State the name and address of the custodian of the plan's books and records and the address at which such records will be located:

   Custodian:

   Location:

9. d. Describe in an attachment hereto the licensee's plans for the termination of its business as a health care service plan or specialized health care service plan, including the following information:

   1. 1. The provision for payment of any amounts due to subscribers and enrollees and the aggregate amount owed thereto.
   2. 2. The provision for payment of any amounts due to providers of health care services, the aggregate owed thereto and a schedule showing the persons to whom such amounts are owed, the amount due each such person, and the date such liability first became due and payable.
   3. 3. The final date for payment of periodic payments by or on behalf of subscribers for health care services, and the final date which the plan will be obligated to furnish health care services by reason of such payments.
   4. 4. If an insurer assumes obligations as to the plans subscribers and enrollees, attach a detailed statement of the plan for the assumption of business by the subsequent provider or insurer, including the provision being made for notice to subscribers and enrollees, group representatives and providers of health care services who contract with the plan.
   5. 5. If the plan or any provider of health care services to the plan holds medical records as to any subscriber or enrollee, indicate the disposition to be made of such records, including the provision made for its subsequent availability to persons providing health care services to such subscribers and enrollees.

10. e. Is the plan's application pursuant to Section 1351 of the Knox-Keene Health Care Service Plan Act of 1975 current, reflecting all matters which require an amendment to such application pursuant to Rules 1300.52, 1300.52.1 or 1300.52.2? Yes ​ No ​

    If “no” attach an amendment(s) to such application in conformance with such rules

11. f. Is the plan currently involved in any civil or administrative proceeding? Yes ​ No ​

    1. 6. The licensee has duly caused this application to be signed on its behalf by the undersigned, thereunto duly authorized.

       (Licensee)

       By

       Title

       I certify under penalty of perjury that I have read this application and the attachments hereto and know the contents thereof, and that the statements therein are true.

       Executed at __________________________________________________ on ____________________

       Signature of Declarant

       If executed in a jurisdiction which does not permit verification under penalty of perjury, attach a verification executed and sworn to before a notary public.

    If “yes” furnish full details, including the court or administrative action before which such matter is pending.

An application to surrender a license as a health plan shall be filed with the Director, in the following form:

DEPARTMENT OF MANAGED HEALTH CARE

STATE OF CALIFORNIA

APPLICATION FOR SURRENDER OF LICENSE PURSUANT TO SECTION 1399, HEALTH AND SAFETY CODE

Date of Application

Dept. of Managed Care

File No.

____________________

Note: Authority cited: Section 1344, Health and Safety Code. Reference: Section 1399, Health and Safety Code.

History

1. Amendment filed 1-12-83; effective thirtieth day thereafter (Register 83, No. 3).

2. Amendment filed 7-3-84; effective thirtieth day thereafter (Register 84, No. 27).

3. Change without regulatory effect amending subsection (e) filed 4-4-2000 pursuant to section 100, title 1, California Code of Regulations (Register 2000, No. 14).

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

5. Change without regulatory effect amending section filed 11-21-2002 pursuant to section 100, title 1, California Code of Regulations (Register 2002, No. 47).