Alternative Insurance Coverage Notification Form

Alternative Insurance Coverage Notification Form Exhibit “B” NOTIFICATION OF ALTERNATIVE INSURANCE COVERAGE FIRST RESPONDER HEALTH AND SAFETY ACT BENEFITS Mail to: MISSISSIPPI INSURANCE DEPARTMENT c/o LEGAL DIVISION – FIRST RESPONDER FUND P.O. Box 79 Jackson, MS 39205-0079 Email to: FirstResponderFund@mid.ms.gov By January 1, 2024, the state, municipality, county or fire protection district is required to provide proof of insurance coverage that meets the requirements of the First Responder Health and Safety Act, or must show satisfactory proof of the ability to pay such compensation to ensure adequate coverage for all eligible first responders to the Commissioner of Insurance. The state, municipalities, counties and fire protection districts may use the Mississippi First Responders Health and Safety Trust Fund (“Fund”) to provide the benefits required under the Act, with the Commissioner of Insurance administering this Fund. However, while the state, municipalities, counties and fire protections districts may access these funds, they are not required to do so and may choose to provide funding for these benefits by using an alternative method. Completion of this form shall provide written notice to the Commissioner of Insurance of the entity’s proof of either insurance coverage or other ability to pay the compensation for any eligible first responder that they are responsible for providing said benefits. Name of Entity ___________________________________________________________________________ Mailing Address City State Zip Code Email Address:_________________________________________________________________ Phone Number:____________________________ Fax Number:_______________________ The above named entity is hereby advising the Commissioner of Insurance that it will not be accessing funds from the Mississippi First Responders Health and Safety Trust Fund to pay for any benefits it may owe to an eligible first responder for calendar year __________________. The entity has obtained the following funds in order to pay said benefits: __________________________ Insurance Coverage • Proof of Insurance must be attached • Coverage amounts must be included ___________________________ Self-Funded • Proof of self-funded plan must be attached • Coverage amounts must be included ____________________________ Other Funding Mechanism • Proof of Funding must be attached • Coverage amounts must be included Certification: I certify that the above information is true and complete to the best of my knowledge. I know that any misrepresentations herein may lead to the Mississippi Insurance Department pursuing civil and/or criminal action for the misrepresentation of such information. _______________________________________________ ______________________________ Entity Representative Name (Please Print) Title _________________________________________ ______________________________ Signature Date