Form Tpa001 B PDF Details

Navigating the complexities of acquiring a non-resident third-party administrator (TPA) license in Idaho involves a thorough understanding of the TPA001-B form and its requirements. The State of Idaho, through its Department of Insurance, mandates a predefined process for companies seeking to operate as non-resident TPAs. Key components of the application process include the submission of the TPA001-B form itself, a detailed checklist for application, a non-resident TPA application form accompanied by a $300 filing fee, and several crucial documents that verify the legitimacy and standing of the applicant company. These documents encompass an original letter of certification or a certificate of good standing from the company's home state, along with a certificate of existence from the Idaho Secretary of State, and a copy of the home state or resident TPA license. Furthermore, the form outlines specific identification and background information requirements for owners, partners, officers, and directors, including disclosures on past criminal convictions, administrative proceedings related to professional licenses, financial solvency, and any legal liabilities pertaining to fraud, misappropriation, or fiduciary breaches. This meticulous documentation is a prerequisite not just for proving the applicant's credibility and legality of operation but also for ensuring that the TPA abides by Idaho's stringent insurance regulations and consumer protection standards. Additionally, the TPA001-B form incorporates a comprehensive certification and attestation section, underscoring the responsibility of the applicant to furnish accurate and complete information, alongside acknowledging familiarity and compliance with relevant insurance laws.

QuestionAnswer
Form NameForm Tpa001 B
Form Length5 pages
Fillable?No
Fillable fields0
Avg. time to fill out1 min 15 sec
Other namesTPA001_B delaware department of insurance tpa checklist form

Form Preview Example

State of Idaho

TPA001-B

Department of Insurance

Idaho Non-Resident TPA Checklist

Applicant Company Name:

 

 

 

FEIN:

 

 

Declared Home State:

 

 

 

 

Approved Home State(s) as of January 2012:

 

 

 

 

Delaware, Indiana, West Virginia

§41-912 (2) An administrator shall not be eligible for a nonresident administrator license under the

provisions of this section if it does not hold a license in a home state that has adopted under the provisions of this chapter or a substantially similar law governing ad i istrators.”

# Required Filing Checklist

1 Form TPA001-B Checklist

2 Non-Resident TPA Application

3 $300 Application/Filing Fee

4 Original Letter of Certification or Certificate of Good Standing issued by Home State

5 Certificate of Existence issued by the Idaho Secretary of State

6 Home State/Resident TPA License (copy accepted)

Application Contact Information

The following individual (company employee or paid consultant) is the authorized representative of the Applicant for this application.

Name:Title:

Company:

E-Mail:Telephone:

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TPA001-B

 

Non-Resident Third Party Administrator License Application

 

 

 

 

 

 

 

Applicant Name

 

 

FEIN

 

Incorporation Date

 

 

 

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DBA/Trade Name (if applicable)

State of Incorporation

Country of Domicile

 

 

 

 

 

 

Business Address

 

 

 

City / State / Zip Code

 

 

 

 

 

 

 

Phone Number

 

Fax Number

E-Mail Address

 

 

 

 

 

 

 

Mailing Address

 

 

 

City / State / Zip Code

 

 

 

 

 

 

 

Owners, Partners, Officers and Directors

Identify sole proprietor or all owners, partners, officers and directors of the applicant (List only those owners with 10% or more ownership)

 

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Title

SSN

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TPA001-B

Background Information

Please read and answer the following questions:

YES NO

1.Has the applicant or any owner, partner, officer or director ever been convicted of, or is the applicant or any owner, partner, officer or director currently charged with, committing a crime, whether or not adjudication was withheld?

“Crime” includes a misdemeanor, felony or a military offense. You may exclude misdemeanor traffic citations and juvenile offenses. “Convicted” includes, but is not limited to, having been found guilty by verdict of a

judge or jury, having entered a plea of guilty or nolo contendre, or having been given probation, a suspended sentence or a fine.

If you answer yes, you must attach to this application:

a.a written statement explaining the circumstances of each incident,

b.a copy of the charging document, and

c.a copy of the official document which demonstrates the resolution of the charges or any final judgment.

2.Has the applicant or any owner, partner, officer or director ever been involved in an administrative proceeding regarding any professional or occupational license?

“Involved” means having a license censured, suspended, revoked, canceled, terminated; or being assessed a fine, placed on probation or surrendering a license to resolve an administrative action. “Involved” also means

being named as a party to an administrative or arbitration proceeding which is related to a professional or occupational license. “Involved” also means having a license application denied or the act of withdrawing an

application to avoid a denial. You may exclude terminations due solely to noncompliance with continuing education requirements or failure to pay a renewal fee.

If you answer yes, you must attach to this application:

a.a written statement identifying the type of license and explaining the circumstances of each incident,

b.a copy of the Notice of Hearing or other document that states the charges and allegations, and

c.a copy of the official document which demonstrates the resolution of the charges or any final judgment.

3.Has any demand been made or judgment rendered against the applicant or any owner, partner, officer or director for overdue monies by an insurer, insured, producer, or anyone else or have you ever been subject to a bankruptcy proceeding?

If you answer yes,

a.submit a statement summarizing the details of the indebtedness and arrangements for repayment.

4.Has the applicant or any owner, partner, officer or director ever been notified by any jurisdiction to which you are applying of any delinquent tax obligation that is not the subject of a repayment agreement?

If you answer yes, identify the jurisdiction(s):____________________________

5.Is the applicant or any owner, partner, officer or director a party to, or ever been found liable in any lawsuit or arbitration proceeding involving allegations of fraud, misappropriation or conversion of funds, misrepresentation or breach of fiduciary duty?

If you answer yes, you must attach to this application:

a.a written statement summarizing the details of each incident,

b.a copy of the Petition, Complaint or other document that commenced the lawsuit or arbitration, and

c.a copy of the official document which demonstrates the resolution of the charges or any final judgment.

6.Has the applicant or any owner, partner, officer or director ever had a contract or any other business relationship terminated for any alleged misconduct?

If you answer yes, you must attach to this application:

a.a written statement summarizing the details of each incident and explaining why you feel this incident should not prevent you from receiving an insurance license, and

b.copies of all relevant documents.

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TPA001-B

Applicant Certification and Attestation

The undersigned owner, partner, officer or director of the applicant hereby certifies, under penalty of perjury, that:

1.All of the information submitted in this application and attachments is true and complete and I am aware that submitting false information or omitting pertinent or material information in connection with this application is grounds for license or registration revocation and may subject me and the applicant to civil or criminal penalties.

2.Where required by law, the applicant hereby designates the Commissioner, Director or Superintendent of Insurance, or an appropriate representative in each jurisdiction for which this application is made to be its agent for service of process regarding all insurance matters in the respective jurisdiction and agree that service upon the Commissioner or Director of that jurisdiction is of the same legal force and validity as personal service upon the applicant.

3.The applicant grants permission to the Commissioner or Director of Insurance in each jurisdiction for which this application is made to verify any information supplied with any federal, state or local government agency, current or former employer or insurance company.

4.Every owner, partner, officer or director of the applicant either a) does not have a current child-support obligation, or b) has a child-support obligation and is currently in compliance with that obligation.

5.I authorize the jurisdictions to give any information they may have concerning me to any federal, state or municipal agency, or any other organization and I release the jurisdictions and any person acting on their behalf from any and all liability of whatever nature by reason of furnishing such information.

6.I acknowledge that I am familiar with the insurance laws and regulations of the jurisdictions to which I am applying for licensure/registration.

7.If required, I have received a Certificate of Good Standing from the jurisdiction's Secretary of State in which I am applying.

Must be signed by an officer, director, principal or partner of the Applicant

Signature

 

Date

 

 

 

Printed Name

 

Title

 

 

 

Address

 

 

 

 

 

City/State/Zip Code

 

 

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TPA001-B

Send all documents and check to:

Idaho Department of Insurance

700West State Street, 3rd Floor Boise, ID 83702-5868

New Applicant Questions Contact

Examinations Section

(208) 334-4311 doi.tpa@doi.idaho.gov

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Be attentive when filling out this form. Make certain every blank field is filled out accurately.

1. Whenever submitting the Form Tpa001 B, be sure to complete all of the important blank fields in their relevant section. It will help to expedite the process, allowing for your information to be processed swiftly and appropriately.

Writing part 1 of Form Tpa001 B

2. Once your current task is complete, take the next step – fill out all of these fields - Original Letter of Certification, Certificate of Existence issued by, Home StateResident TPA License, Application Contact Information, The following individual company, Name, Company, EMail, Title, and Telephone with their corresponding information. Make sure to double check that everything has been entered correctly before continuing!

Form Tpa001 B completion process clarified (step 2)

3. The following segment is mostly about Applicant Name DBATrade Name if, FEIN State of Incorporation, Incorporation Date, Country of Domicile, Business Address, City State Zip Code, Phone Number, Fax Number, EMail Address, Mailing Address, City State Zip Code, Owners Partners Officers and, Identify sole proprietor or all, Name, and Title - fill out each one of these blank fields.

Stage no. 3 in submitting Form Tpa001 B

4. To go forward, this next section will require filling out a couple of empty form fields. Included in these are , which you'll find fundamental to carrying on with this particular process.

Form Tpa001 B writing process explained (portion 4)

5. As you draw near to the conclusion of this form, you'll notice several more things to complete. Mainly, YES NO, Has the applicant or any owner, partner officer or director, Crime includes a misdemeanor, a b c, a written statement explaining the, Has the applicant or any owner, regarding any professional or, Involved means having a license, If you answer yes you must attach, a b c, and a written statement identifying should all be done.

The best ways to prepare Form Tpa001 B step 5

People who use this PDF frequently make mistakes while filling out Crime includes a misdemeanor in this area. Be sure you review everything you type in here.

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