APPENDIX E. HMO FORM E
PRE-NOTIFICATION FORM
REGARDING THE POTENTIAL COMPETITIVE IMPACT
OF A PROPOSED MERGER OR ACQUISITION BY A
NON-DOMICILIARY HMO DOING BUSINESS IN THIS
STATE OR BY A DOMESTIC HMO
______________________________
Name of Applicant
______________________________
Name of Other Person
Involved in Merger or
Acquisition
Filed with the Insurance Department of
_________________________________________________________________
Dated: ____________________, 20______.
Name, title, address and telephone number of person completing this statement:
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
ITEM 1. NAME AND ADDRESS
State the names and addresses of the persons who hereby provide notice of their involvement in a pending acquisition or change in corporate control.
ITEM 2. NAME AND ADDRESSES OF AFFILIATED COMPANIES
State the names and addresses of the persons affiliated with those listed in Item 1. Describe their affiliations.
ITEM 3. NATURE AND PURPOSE OF THE PROPOSED MERGER OR ACQUISITION
State the nature and purpose of the proposed merger or acquisition.
ITEM 4. NATURE OF BUSINESS
State the nature of the business performed by each of the persons identified in response to Item 1 and Item 2.
ITEM 5. MARKET AND MARKET SHARE
State specifically what market and market share in each relevant HMO market and persons identified in Item 1 and Item 2 currently enjoy in this state. Provide historical market and market share data for each person identified in Item 1 and Item 2 for the past five years and identify the source of such data. For purposes of this question, market means direct written premium in this state for a line of business as contained in the annual statement required to be filed by insurers licensed to do business in this state.
NOTE: State Insurance Departments may additionally choose to make these calculations using their own data or data provided by the NAIC.
