Ohio Form Ins3213 PDF Details

Ohio Form Ins3213 is a form that is used to request an exemption from the state income tax. The form can be used to request an exemption for a variety of reasons, including religious purposes. The form must be completed and submitted to the Ohio Department of Taxation in order to receive an exemption from state income tax.

You could find it useful to know how much time you'll need to fill in this ohio form ins3213 and how long this form is.

QuestionAnswer
Form NameOhio Form Ins3213
Form Length3 pages
Fillable?Yes
Fillable fields98
Avg. time to fill out20 min 25 sec
Other namesINS3213 ohio department of insurance tpa 2013 renewal form

Form Preview Example

Judith L. French, Director

Check appropriate boxes for license requested:

(Please Print or Type)

Resident License

Non-Resident License

Identify Home State:

Identify Home State License #:

Demographic Information

1Business Entity’s Name

2FEIN

3Ohio License Number

4National Producer Number (NPN)

5 Is the business entity affiliated with a financial institution/bank?

Yes

No

6Business Address

7City

8State

9Zip or Foreign Country

10Phone Number (include extension)

11Fax Number

12Business E-Mail Address

13Business Web Site Address

14Mailing Address

15P.O. Box

16City

17State

18Zip or Foreign County

Designated/Responsible Licensed Producer

19Identify at least one Designated/Responsible Licensed Producer responsible for the business entity’s compliance with the insurance laws, rules, and regulations of this state:

Name

 

SSN

 

NPN

Name

 

SSN

 

NPN

Name

 

SSN

 

NPN

Name

 

SSN

 

NPN

Background Questions

20

 

 

 

1a. Has the business entity or any owner, partner, officer or director of the business entity, or member or manager of a limited liability company

 

Yes

No

been convicted of, or is currently charged with, committing a MISDEMEANOR or had a judgment withheld or deferred for a

 

 

 

MISDEMEANOR which has not been previously reported to this insurance department?

 

 

 

You may exclude the following misdemeanor convictions or pending misdemeanor charges: traffic citations, driving under the influence

 

 

 

(DUI), driving while intoxicated (DWI), driving without a license, reckless driving, or driving with a suspended or revoked license.

 

 

 

You may also exclude juvenile adjudications (offenses where you were adjudicated delinquent in a juvenile court).

 

 

 

1b. Has the business entity or any owner, partner, officer or director of the business entity, or member or manager of a limited liability company

 

Yes

No

been convicted of, or is currently charged with, committing a FELONY or had a judgment withheld or deferred for a FELONY which has

 

 

 

not been previously reported to this insurance department?

 

 

 

You may also exclude juvenile adjudications (offenses where you were adjudicated delinquent in a juvenile court).

 

 

 

If you have a felony conviction involving dishonesty or breach of trust, have you applied for written consent to engage in the business of

N/A

Yes

No

insurance in your home state as required by 18 USC 1033?

 

 

 

If so, was consent granted? (Attach copy of 1033 consent approved by home state.)

N/A

Yes

No

1c. Has the business entity or any owner, partner, officer or director of the business entity, or member or manager of a limited liability company

 

Yes

No

been convicted of, or is currently charged with a MILITARY OFFENSE which has not been previously reported to this insurance

 

 

 

department?

 

 

 

NOTE: For Questions 1a, 1b, and 1c, “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 contendere or no contest, or having been given probation, a suspended sentence, or a fine.

If you answered “Yes” to any of the above questions (1a, 1b, or 1c), 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.

INS3213 (Rev. 02/2021)

Page 1 of 3

Ohio Department of InsuranceBUSINESS ENTITY TPA LICENSE RENEWAL/CONTINUATION

Background Questions (continued)

2. Has the business entity or any owner, partner, officer or director, or manager or member of a limited liability company, been named or

Yes

No

involved as a party in an administrative proceeding regarding any professional or occupational license or registration, which has not been previously reported to this state?

“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 “Yes”, you must attach to this application:

a)a written statement identifying the type of license; identifying all parties involved (including their percentage of ownership, if any) 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.

Does the TPA hold a fidelity bond or other comparable insurance policy coverage for all employees as required by R.C. 3959.11 and

Yes

No

 

OAC 3901-8-05 (D) (5)?

 

 

 

If “Yes”, provide a copy of bond or insurance policy coverage. Make sure documentation includes the name of the carrier, policy number

 

 

 

and effective dates.

 

 

4.

Does the TPA carry any type of professional liability and/or E&O insurance for TPA activities as required by ERISA?

Yes

No

 

If “Yes”, provide proof of coverage or bond. Make sure documentation includes the name of the carrier, policy number and effective dates.

 

 

5.

Do you understand that any required bond, insurance policy, professional liability and E&O insurance policy must be maintained for

Yes

No

 

the duration of the licensure period?

 

 

6.Will the TPA’s records continue to be maintained in accordance with the requirements of OAC 3901-8-05 (L) and (M)? If the

 

answer to any of the questions below is “No”, then attach a letter stating how those records are maintained.

 

 

 

a)

Records reflect all administered transactions?

 

Yes

No

 

b)

Detailed preparation or journalizing and posting of books and records are maintained?

Yes

No

 

c)

Records are maintained throughout the term of the administration agreement?

 

Yes

No

 

d)

All disbursement records contain the information required by R.C. 3959.15 (E)-(H)?

Yes

No

 

e)

Annual reports are required to be filed with insurers and plan sponsors within 90 days of the end of each fiscal year of the plan?

Yes

No

 

f)

Return premiums or contributions are paid to insurer or plan sponsors within 30 days of receipt?

Yes

No

7.

Since the last application or renewal have any Excess Insurers (Stop-Loss Carriers) or Managing General Underwriters approved the TPA to

Yes

No

 

administer claims for plans using their stop-loss products?

 

 

 

 

If “Yes”, provide the names and contact information for each one on a separate document.

 

 

 

8.

Since the last application or renewal has the TPA been licensed as a Managing General Agent?

Yes

No

 

If “Yes”, provide a name of the States and license status on a separate document.

 

 

 

9.

What type(s) of claims will the TPA administer or plan to administer within the next year in this state?

 

 

 

(Must check at least one option – Select all appropriate options that apply)

 

 

 

 

 

Traditional self-insured employee benefit plans

Government self-insured employee benefit plans

 

 

 

 

Preferred Provider Org. (PPO)

Fully insured employee benefit plans

 

 

 

 

Prescription drug claims

Provider billing processing

 

 

 

 

Life insurance claims

Medical/Managed care

 

 

 

 

Disability insurance claims

Other, attach description on a separate document.

 

 

 

 

Dental claims

 

 

 

10. How does the TPA handle plan sponsor and insurer funds?

 

 

 

 

(Must check at least one option – Select all appropriate options that apply)

 

 

 

 

 

Accounts are owned by the insurance company

 

 

 

 

 

Plan sponsor owns accounts/TPA has check writing ability

 

 

 

 

 

TPA has a separate fiduciary account(s) for plan sponsor & insurer funds

 

 

 

 

 

OTHER: Attach a letter of explanation.

 

 

 

11. Does the applicant understand that the TPA and its officers shall be responsible for the supervision of the actions of any and all personnel

Yes

No

 

and subcontractors who adjust or settle claims on behalf of the applicant according to OAC 3901-8-05 (E)(3)?

 

 

Applicant’s Signature:

Ohio Department of InsuranceBUSINESS ENTITY TPA LICENSE RENEWAL/CONTINUATION

Background Questions (continued)

 

12.

Does the applicant understand that the TPA may not commingle among its personal assets, or draw against for its own purposes, any

Yes

No

 

 

monies or contributions of a plan sponsor or plan participant according to OAC 3901-8-05 (H)(1)?

 

 

 

13.

Have there been any changes of officers, directors, partners, members or trustees, or any change of shareholders or other owners or

Yes

No

 

 

members holding 5% or more ownership in the TPA or change of business address that has not been previously reported to the Department

 

 

 

 

as required by OAC 3901-8-05(D)(5)?

 

 

 

 

If “Yes”, include the Department’s document for business entity changes.

 

 

 

14.

Is the TPA operating as a Pharmacy Benefit Manager (PBM)?

Yes

No

 

 

 

 

 

 

 

 

Applicant’s Certification and Attestation

21

On behalf of the business entity or limited liability company, the undersigned owner, partner, officer or director of the business entity, or member or manager of a limited liability company, 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 business entity or limited liability company to civil or criminal penalties.

2.Unless provided otherwise by law or regulation of the jurisdiction, the business entity or limited liability company hereby designate the Commissioner, Director or Superintendent of Insurance, or other appropriate party 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, Director or Superintendent of Insurance, or other appropriate party of that jurisdiction is of the same legal force and validity as personal service upon the business entity.

3.The business entity or limited liability company grants permission to the Commissioner, Director or Superintendent of Insurance, or other appropriate party in each jurisdiction for which this application is made to verify information with any federal, state or local government agency, current or former employer, or insurance company.

4.Every owner, partner, officer or director of the business entity, or member or manager of a limited liability company, 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 concerning me, as permitted by law, 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 understand and will comply with the insurance laws and regulations of the jurisdictions to which I am applying for licensure/registration.

7.For Non-Resident License Applications, I certify that I am licensed and in good standing in my home state/resident state for the lines of authority requested from the non-resident state.

8.I hereby certify that upon request, I will furnish the jurisdiction(s) to which I am applying, certified copies of any documents attached to this application or requested by the jurisdiction(s).

Must be signed by an officer, director, or partner of the business entity, or member or manager if a limited liability company who has authority to act on behalf of the business entity:

Signature

Type or Print Name

Title

Address

Date

Social Security Number

City

State

Zip

Application Attachments

22The following attachments must accompany the application; otherwise the application may be returned unprocessed or considered deficient.

1.Non-refundable fee (check or money order) made payable to the “State of Ohio Treasurer” in the amount of $300.00;

2.Provide proof of fidelity bond or other comparable insurance policy coverage for all employees as required by R.C. 3959.11 and OAC 3901-8-05 (D)(5). (Documentation must include the name of the carrier, policy number and effective dates.)

3.Provide proof of professional liability insurance coverage and/or E&O insurance as required by ERISA. (Documentation must include the name of the carrier, policy number and effective dates.); and

4.If necessary, any required supporting details or documents.

Requirements for Licensure

23

1.All business entity TPA applicants must be registered with the Ohio Secretary of State.

2.Non-Resident TPA applicants must be registered with the home state Secretary of State.

INS3213 (Rev. 02/2021)

Page 3 of 3

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