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Blank Indiana M400 PDF Template

The Indiana M400 form is a renewal application used for registering a Multiple Employer Welfare Arrangement (MEWA). This form is essential for entities that provide employee benefits, such as accident and sickness or death benefits, to employees of two or more employers. Completing the M400 ensures compliance with state regulations and helps maintain the benefits offered to employees and their dependents.

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Outline

The Indiana M400 form serves as a critical tool for organizations seeking to renew their registration as a Multiple Employer Welfare Arrangement (MEWA). This form is designed for entities that provide employee benefit plans, specifically those offering accident and sickness or death benefits to employees from at least two different employers, including self-employed individuals. Applicants must certify whether there have been changes to their previously submitted application information and documentation, which is a key aspect of the renewal process. The form requires essential details such as the full name and statutory home address of the MEWA, as well as a mailing address and contact information for a designated representative. Additionally, applicants must indicate if the employers within the MEWA are part of a trade association and whether that association plays an active role beyond mere sponsorship. Other important considerations include the fiscal year of the MEWA, its non-profit status, and any existing contracts with third-party administrators. The form also inquires about the fund balance of the MEWA and requires the signature of the Chair of the Board, affirming the accuracy of the provided information. This comprehensive approach ensures that the MEWA remains compliant with state regulations and continues to operate effectively for the benefit of its members.

Form Sample

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

(7.)

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

yes

If answer is no please explain:

(8.)

Has the MEWA’s fiscal year changed?

(9.)

Is the MEWA a non-for-profit organization?

yes

(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

administrator(s):

(11.)

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

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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Form Specifics

Fact Name	Fact Details
Form Purpose	The Indiana M400 form is a renewal application for the registration of Multiple Employer Welfare Arrangements (MEWAs).
Governing Law	This form is governed by Indiana Code IC 27-1-34-1.
Definition of MEWA	A MEWA is an entity that provides employee benefit plans, offering accident and sickness or death benefits to employees of at least two employers.
Certification Requirement	Applicants must certify whether there have been changes to the previously submitted application information.
Address Information	The form requires both the statutory home address and mailing address of the MEWA.
Contact Information	Applicants must provide a contact person’s name, title, and telephone number for the MEWA.
Association Membership	The form inquires if employers in the MEWA are members of an association or group in the same trade or industry.
Non-Profit Status	Applicants must indicate whether the MEWA is a non-profit organization.
Fiscal Year Changes	The form asks if there have been any changes to the MEWA’s fiscal year.

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