Indiana Form M400 PDF Details

In Indiana, the M400 form plays a critical role for Multiple Employer Welfare Arrangements (MEWAs) aiming to renew their registration, ensuring the provision of accident, sickness, or death benefits to employees across various employers. This form represents a formal renewal application that must be filled out and submitted in accordance with the IC 27-1-34-1 regulation. It covers several significant data points, including the MEWA's full name, statutory and mailing addresses, and a designated contact person, ensuring clear lines of communication. Applicants must indicate whether any changes have occurred in the previously submitted information or documentation over the last year, thereby necessitating the inclusion of updated materials if applicable. The form also explores the relationship between the MEWA and any associations or groups of businesses, shedding light on the collaborative nature of these arrangements. Moreover, it queries the MEWA's non-profit status, fiscal changes, and connections with third-party administrators, offering insights into the organizational and operational structure of the MEWA. Finally, a certification section, where the chair of the board attests to the veracity of the information provided, underscores the form's legal significance. Through this detailed documentation process, the Indiana M400 form ensures MEWAs are thoroughly vetted and compliant, thereby safeguarding the welfare benefits of countless employees and their dependents.

QuestionAnswer
Form NameIndiana Form M400
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesMEWAs, Ver, sponsorship, establishes

Form Preview Example

RENEWAL APPLICATION FOR REGISTRATION OF MULTIPLE

EMPLOYER WELFARE ARRANGEMENT (MEWA)-IC 27-1-34-1

NOTE: “Multiple Employer Welfare Arrangement” means an entity other than a duly admitted insurer that establishes an employee benefit plan for the purpose of offering or providing accident and sickness or death benefits to the employees of at least two (2) employers, including self-employed individuals and their dependents.

(1.)

Applicants Certification:

 

 

 

 

 

 

 

 

 

 

(A.)

I certify that

there have been no changes to the application information and documentation submitted during the last year

 

 

 

 

 

 

 

 

 

(B.)

I certify that

there have been changes to the previously submitted application information and documentation and have

 

attached the revised documentation.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(2.)

Full name of MEWA

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(3.)

Statutory home address of MEWA (street, city, state, ZIP code)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(4.)

Mailing address of MEWA (street, city, state, ZIP code)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(5.)

Contact person of MEWA

(5a.) Title

 

 

 

 

 

(5b.) Telephone number

 

 

 

 

 

 

 

 

 

 

 

 

(

)

 

 

 

 

 

 

 

 

 

 

 

(6.)

Are the employers in the MEWA members of an association or

(6a.) List trade or industry:

 

 

 

 

 

group of two (2) or more businesses in the same trade or

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

industry ?

yes

 

no

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(7.)

Is the association substantially involved in the activity for its members other than sponsorship?

yes

no

 

If answer is no please explain:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(8.)

Has the MEWA’s fiscal year changed?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(9.)

Is the MEWA a non-for-profit organization?

yes

no

 

 

 

 

 

 

 

 

 

 

 

 

(10.) Does the MEWA have a contract with a third party

 

 

(10a.) If answer is yes list or attached the name of the third party

 

administrator?

yes

no

 

 

 

 

administrator(s):

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(11.)

Are any of the trustees an owner, officer, or employee if the administrator? yes

no

 

 

 

 

 

If yes, please explain:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(12.)

What is the MEWA’s fund balance?

 

 

 

 

 

 

 

 

 

 

 

Comments:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

I certify that the above statements are true.

 

 

 

 

 

 

 

 

 

 

Signature of Chair of Board

 

 

 

Date

 

Printed Name of Signature

 

 

 

Title

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Form M400

Ver. 1.0

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