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Microsoft Word Document (doc) - INS3212

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Check appropriate box for license requested: ☐ Resident License. ☐ Non- Resident License. Identify Home State License: Identify Home State License Number: ...

    Licensing Division Ohio Department of Insurance 50 W. Town St., 3rd Fl. John R. Kasich Governor Suite 300 Mary Taylor Lt. Governor/Director Columbus, OH 43215 (614) 644-2665 Individual Third Party Administrators (TPA) Fax # (614) 387-0087 www.insurance.ohio.gov License Renewal/Continuation

    (Please Print or Type)

    Check appropriate box for license requested:

     Resident License

     Non-Resident License

    ; Identify Home State License:

    ; Identify Home State License Number:

    1 2 3 Social Security Number Date of Birth If assigned National Producer Number (NPN)

4 Last Name JR./SR. etc 5 First Name

    9 Residence/Home Address (Physical Street) City State Zip or Foreign Country 7 6 8

     Business Entity’s Name 10

    12 13 15 11 Business Address (Physical Street) P.O. Box City State Zip or Foreign Country 14

    1819 17 16 Business Phone Number Business Fax Number Business E-Mail Address Business Web Site Address 18 (include extension) ( ) ( ) 23 Mailing Address P.O. Box City State Zip or Foreign Country 20 21 22 24

     List your Insurance Agency Affiliations: (Complete only if the applicant is to be licensed as an active member of the business entity) 25

    FEIN NPN Name of Agency FEIN NPN Name of Agency FEIN NPN Name of Agency

     The Producer must read the following very carefully and answer every question: 26 1. Have you been convicted of a crime, had a judgment withheld or deferred, or are you currently charged with committing a crime, which has Yes No not been previously reported to this state? “Crime” includes a misdemeanor, felony or a military offense. You may exclude misdemeanor traffic citations or convictions involving driving under the influence (DUI) or driving while intoxicated (DWI), driving without a license, reckless driving, or driving with a suspended or revoked license 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 contendere (no contest), 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. If you have a felony conviction, have you applied for a waiver as required by 18 USC 1033? N/A Yes No If so, was that waiver granted? (Attach copy of 1033 waiver approved by home state.) N/A Yes No

     Accredited by the National Association of Insurance Commissioners (NAIC) INS3212 (Rev. 01/2011) Page 1 of 3

    Ohio Department of Insurance INDIVIDUAL TPA LICENSE RENEWAL/CONTINUATION

     2. Have you been named or involved as a party in an administrative proceeding regarding any professional or occupational license or Yes No 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. INCLUDE any business so named because of your actions in your capacity as an owner, partner officer, director, or member or manager of a Limited Liability Company. 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. Do you have a child support obligation in arrearage, which has not been previously reported to this state? Yes No If you answer yes,

    a) by how many months are you in arrearage? Months

    b) are you currently subject to and in compliance with any repayment agreement? Yes No

    c) are you the subject of a child support related subpoena/warrant? Yes No 4. Does the TPA hold a fidelity bond or other comparable insurance policy coverage for all employees as required by R.C. 3959.11 and OAC Yes No 3901-8-05 (D) (5)? If you answered yes, provide a copy of bond or insurance policy coverage. Make sure documentation includes the name of the carrier, policy number and effective dates. 5. Does the TPA carry any type of professional liability and/or E&O insurance for TPA activities as required by ERISA? Yes No If you answered yes, provide proof of coverage or bond. Make sure documentation includes the name of the carrier, policy number and effective dates. 6. Do you understand that any required bond, insurance policy, professional liability and E&O insurance policy must be maintained for the Yes No duration of the licensure period? 7. 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 8. Since the last application or renewal have any Excess Insurers (Stop-Loss Carriers) or Managing General Underwriters approved the TPA Yes No to administer claims for plans using their stop-loss products? If you answered yes, provide names and contact information for each one on a separate document. 9. Since the last application or renewal has the TPA been licensed as a Managing General Agent? Yes No If you answered yes, provide a name of the States and license status on a separate document. 10. 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 Check 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 Applicant’s Initials

     Accredited by the National Association of Insurance Commissioners (NAIC) INS3212 (Rev. 01/2011) Page 2 of 3

    Ohio Department of Insurance INDIVIDUAL TPA LICENSE RENEWAL/CONTINUATION

     11. How does the TPA handle plan sponsor and insurer funds? (Must check at least one option Check 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. 12. 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)? 13. 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)? 14. 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 you answered yes, include the Department’s document for business entity changes.

     The Producer must read the following very carefully: 27

    1. I hereby certify that, under penalty of perjury, all of the information submitted in this application and attachments is true and complete. I am aware that submitting false information or omitting pertinent or material information in connection with this application is grounds for license revocation or denial of the license and may subject me to civil or criminal penalties.

    2. Unless provided otherwise by law or regulation of the jurisdiction, I hereby designate the Commissioner, Director or Superintendent of Insurance, or other appropriate party in each jurisdiction for which this application is made to be my 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 myself.

    3. I further certify that I grant 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. I further certify that, under penalty of perjury, (a) I have no child-support obligation, (b) I have a child-support obligation and I am currently in compliance with that obligation, or (c) I have identified my child support obligation arrearage on this application.

    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. 7. 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).

     Original Producer Signature Date

     Full Legal Name (Printed or Typed)

    28 The 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.);

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

     Accredited by the National Association of Insurance Commissioners (NAIC) INS3212 (Rev. 01/2011) Page 3 of 3

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