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Medical Discount Plan License Application

Medical Discount Plan License Application

 

INSTRUCTIONS: CONNECTICUT MEDICAL DISCOUNT PLAN (MDP) LICENSE APPLICATION

 

 

To apply for a medical discount plan (MDP) license in Connecticut, use the form discussed in this article. This document can be obtained from the website of the government of Connecticut.

 

Connecticut Medical Discount Plan (MDP) License Application Step 1: The first page contains general instructions for filing this application.

 

Connecticut Medical Discount Plan (MDP) License Application Step 2: Enter the calendar year for which you are filing on the first blank line of the second page.

 

Connecticut Medical Discount Plan (MDP) License Application Step 3: Enter the name of the MDP on the second blank line.

 

Connecticut Medical Discount Plan (MDP) License Application Step 4: Enter the email address of the MDP on the third blank line.

 

Connecticut Medical Discount Plan (MDP) License Application Step 5: List all names used to market your MDP card on the fourth blank line.

 

Connecticut Medical Discount Plan (MDP) License Application Step 6: Enter your MDP tax identification number or federal employer identification number on the fifth blank line.

 

Connecticut Medical Discount Plan (MDP) License Application Step 7: Enter your MDP business address on the next three blank lines.

 

Connecticut Medical Discount Plan (MDP) License Application Step 8: If your MDP mailing address is different from your business address, enter it on the next two blank lines.

 

Connecticut Medical Discount Plan (MDP) License Application Step 9: Enter your MDP phone number on the next blank line.

 

Connecticut Medical Discount Plan (MDP) License Application Step 10: The next section concerns contact information to be used for all future related correspondence. On the first two blank lines, enter the name and title of a contact person.

 

Connecticut Medical Discount Plan (MDP) License Application Step 11: Enter the contact person's mailing address on the next two blank lines.

 

Connecticut Medical Discount Plan (MDP) License Application Step 12: Enter the contact person's phone number and fax number on the next two blank lines.

 

Connecticut Medical Discount Plan (MDP) License Application Step 13: Enter the name and a description of your controlling company and organization.

 

Connecticut Medical Discount Plan (MDP) License Application Step 14: Enter a contact name for the controlling company or organization.

 

Connecticut Medical Discount Plan (MDP) License Application Step 15: Complete the remainder of the application as instructed.

 

Download the PDF file .

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