Question	Answer
Form Name	Ohio Form Ins3213
Form Length	3 pages
Fillable?	Yes
Fillable fields	98
Avg. time to fill out	20 min 25 sec
Other names	INS3213 ohio department of insurance tpa 2013 renewal form

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?

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?

	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)?

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

Name	SSN	NPN
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