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To register as a Multiple Employer Welfare Arrangement (MEWA) please submit the application in a three-ring binder tabbed according to the list of required items in the application.
Each application question must be completed in full. Attach a separate sheet of paper, properly signed, if additional space is needed.
NOTE: The word "registrant" refers to the MEWA making application.
- Application - Form M100 (Item 1)
- Biographical Affidavit Form 11 (originally signed and notarized) - (Item 15)
- Organizational Requirements Checklist - Form M200 - (Item 17)
- MEWA Coverage Affidavit - Form M500 - Item 18
- MEWA Coverage Requirements Checklist - Form M300 - Item 19
- Management Discussion & Analysis
Registration fee of $350 payable to: Indiana Department of Insurance
Send the completed application and information to:
Indiana Department of Insurance
311 West Washington Street, Suite 300
Indianapolis, Indiana 46204-2787
After we receive the proper filing and review is completed, a letter of registration will be prepared and sent to the contact person listed on the application.