Indiana Code 28-8-4.1-703. Quarterly report of authorized delegates; contents
(1) Company legal name.
(2) Taxpayer employer identification number.
(3) Principal provider identifier.
(4) Physical address.
(5) Mailing address.
(6) Any business conducted in other states.
(7) Any fictitious or trade name.
(8) The name, telephone number, and electronic mail address for the authorized delegate’s contact person.
(9) Start date as the licensee’s authorized delegate.
(10) End date for acting as licensee’s authorized delegate, if applicable.
(11) Court orders issued under section 803 of this chapter against the authorized delegate.
(12) Any other information the director reasonably requires with respect to the authorized delegate.
As added by P.L.198-2023, SEC.4.