Missouri Revised Statutes Title XXIV. Business and Financial Institutions § 376.1005. Application for certificate of authority, form--fee--policy or other evidence of coverage provided to employees, form

1. Application for a certificate of authority shall be made on forms prescribed by the director of the department of commerce and insurance. No multiple employer self-insured health plan may hold or obtain a certificate of authority unless it had not less than two hundred fifty covered employees during the preceding calendar quarter.

2. Not later than March first of each year, every multiple employer self-insured health plan shall pay to the director a license fee equal to two percent of the Missouri claims paid by the plan during the immediately preceding calendar year. All the funds collected by the director shall be deposited in the Missouri department of commerce and insurance dedicated fund.

3. Within forty-five days from the date coverage commences, the plan shall issue to each covered employee a policy, contract, certificate, summary plan description or other evidence of the benefits and coverages provided. This evidence of the benefits and coverages provided shall contain in boldfaced print in a conspicuous location, the following statement:

“The benefits and coverages described herein are provided through a trust fund established and funded by a group of employers. The benefits and coverages are not fully insured by aninsurer licensed to do business in the state of Missouri and are therefore not protected by the Missouri Life and Health Guaranty Association”.