Department of Labor and Regulation

Title - Division of Insurance email the Division of Insurance

Surety Bond Form or Submit Depository Information for Discount Medical Plan Organizations

A surety bond form, DMPO Surety Bond Form (in Adobe .pdf format), is required to be completed and provided to the Division. This may be faxed to 605.773.5369 or emailed to insurance@state.sd.us. Please put "DMPO Application" in the subject line of the email.

DMPO Surety Bond Form (Adobe .pdf format*)

Surety Bond Form or Submit Depository Information

Principal/Applicant - The name and address should match that of the applicant on the registration form.

Signed and Sealed - The completion of the upper half of page 2 for the applicable entity structure is required.

Acknowledgement of Principal - Principal must complete the type of acknowledgement that is applicable to their entity's structure.

Individual, Partnership or Corporate Surety - Surety must complete this portion and have it signed by a South Dakota Resident Agent.

Acknowledgement of Surety - Surety must complete the applicable acknowledgement section.

Note: In lieu of the bond required, a registered discount medical plan organization may deposit and maintain deposited with the director, or at the discretion of the director, with any organization or trustee acceptable to the director through which a custodial or controlled account is utilized, cash, securities or any combination of these or other measures that are acceptable to the director which at all times have a market value of not less than $35,000. All income from the deposit is an asset of the discount medical plan organization. For entities that want to meet their financial security by this means instead of the surety bond, written documentation is required from the depository.

*Opening and printing Adobe .pdf files requires Adobe Acrobat Reader. Click here as needed to download the free Adobe Acrobat Reader.

 

 

 

 


Division of Insurance
445 E. Capitol Avenue
Pierre, SD 57501
Tel. 605.773.3563
Fax. 605.773.5369