Illinois Form Tpa 1 – Fill Out and Use This PDF

Third Party Administrator – License Application TPA-1

Instructions: Print or type all information except that which requires a signature.

Fee Requirement: Attach a check or money order payable to the Director of Insurance for $200.

Note: A TPA license is not required to administer fire and casualty funds or claims.

7. Type of business organization (check one)

(	)	Corporation
		State of incorporation ________________________________	Year of Incorporation __________
(	)	Partnership
		Year of formation _____________
(	)	Proprietorship
		Year of formation _____________

If the TPA is registered under an assumed name, attach a copy of the DBA registration to this application.

8.Enter the name, official title or position and residence address of the person(s) assuming responsibility for the conduct ofthe TPA.

Name ________________________________________ Title ____________________________________________

Address _________________________________________________________________________________________

Name ________________________________________ Title ____________________________________________

Address _________________________________________________________________________________________

Name ________________________________________ Title ____________________________________________

Address _________________________________________________________________________________________

If more space is needed, attach a separate sheet listing additional persons.

9.Bond Requirement. Unless the administrator is contracted with the insurer as an adminstrator and the plan is fully insured by the insurer on whose behalf the funds are held, each applicant for an administrator license must file with the application and thereafter maintain in force while so licensed, a surety bond favor of the people of the State of Illinois executed by a surety company and payable to any party injured under the terms of the bond. The bond shall be continous in form and in one of the following amounts:

1)For an administrator which maintains an Administrator Trust Fund (ATF) but does not maintain a Claims Administration Services Account (CASA), the greater of $50,000 or 5% of contributions and premiums projected to be received or collected in the ATF for the forthcoming plan year from Illinois residents but not exceed $1,000,000.

2)For an administrator which maintains a CASA but does not maintain an ATF, the greater of $50,000 or 5% of the claims and claims expenses projected to be held in the CASA for the forthcoming year to pay claims and claims expenses for Illinois residents, but not exceed $1,000,000.

3)For an administrator which maintains both an ATF and a CASA, the greater of the amounts in (1) or (2) above, but not to exceed $1,000,000.

Indicate the amount of contributions and premiums estimated to be received during the forthcoming year in the administrative trust fund. $______________________________________________

Indicate the amount of claims and claims adjustment expenses estimated to be paid during the forthcoming year from the claims administration. $______________________________________________

10. Bond Exemption. Check box if claiming bond exemption. o

I, ________________________________________________, do not maintain an Administrative Trust Fund (ATF) or a

(Name of Administrator)

Claims Administration Services Account (CASA). Therefore, I claim exemption from the bond requirement for adminstrators as set forth above.

Yes

No

11.Has any administrator license applied for or issued to applicant or any person listed under No.8 on the reverse side ever been denied, suspended, revoked or surrendered as a remedy for regulatory action? If “yes,” attach a copy of the order.

12.Has the applicant or any persons listed under No. 8 ever been convicted of a felony or entered a plea of nolo contendre to a criminal action? If “yes,” attach a certified copy of the indictment, judgement and sentencing order.

13.Is the applicant licensed in its state of domicile?

14.Are any of the applicant’s books, records, documents or other papers relating to the applicant’s business affairs located, or created by processes or functions located, outside of the United States?

15.Does the applicant have a written executed agreement(s) with the insurer(s) or plan sponsor(s) as required under section 511.106(d)? If “yes,” give name and address of each insurer or plan sponsor, execution date(s) and termination date(s). If “no,” explain in detail. Attach a separate sheet.

16.Does the applicant have any written agreement(s) with any insurer or plan sponsor(s) that do not assume or bear the risk? If ”yes,” attach a separate sheet with the name(s), address(es) of the ultimate risk bearers pursuant to Section 511.106(d).

17.Has the applicant even been affiliated with an insurer or plan sponsor which was unable to meet its claim or other financial obligations on a current basis from the assets of the plan?

18.Will this license be used to administer any other life, accident and health plans?

19.The applicant and any person listed under No. 8 shall identify any ownership interest of affiliation of any kind with any plan sponsor or insurer which is responsible directly or through reinsurance for providing benefits to any plan for which the applicant provides services as an administrator. List name(s) and address(es) and what interest or affiliation.

________________________________________________________________________________________________

________________________________________________________________________________________________

20.List the names and official positions of all the individuals not listed in No. 8 on page 1 who are members of the boards of directors, board of trustees, executive committee, or other governing board or committee, officers in the case of a corporation, and the partners or members in the case of a partnership or association. If any person listed is not a natural person, list the directors, members, and responsible person with that organization.

____________________________	____________________________	____________________________
____________________________	____________________________	____________________________
____________________________	____________________________	____________________________
____________________________	____________________________	____________________________
____________________________	____________________________	____________________________

If more space is needed, please attach separate sheet listing additional person.

I, ____________________________________________, being duly sworn and on oath, state that I am an

officer/principal/proprietor of the above listed TPA, and that I am authorized and directed to file this application for a license to operate as a third party administrator in the State of Illinois. If granted a license, the TPA agrees that it will comply with all valid and legal requirements of statutes and the Director of Insurance insofar as they relate to the operation of applicant as a TPA. The TPA also specifically agrees that it will notify the Director of Insurance of any significant change in information required in this application or otherwise within 30 days, and that any service of process sent to the above indicated address with be deemed to have been served on the TPA.

We hereby apply for a license to operate a third party administrator in the State of Illinois.

__________________________________________	_______________________________________________
Date of Signing	Signature of Principal

Important Notice: Disclosure of this information is required under the Illinois Revised Statutes’ insurance laws. Failure to provide this information will result in this form not being processed. This form has been approved by the Forms Management Center.

IL446-0177 (Rev. 2/13) IOCI 13-471

TPA-1 (page 2 of 2)