The Illinois TPA 1 form is a license application specifically designed for third-party administrators operating in the state of Illinois. This form is essential for those seeking to administer various insurance funds and claims, ensuring compliance with state regulations. Completing the TPA 1 form accurately is crucial, as it includes important details about the applicant's business structure, financial obligations, and any potential legal issues.
The Illinois TPA 1 form serves as the official application for a Third Party Administrator (TPA) license in the state of Illinois. This form is essential for businesses seeking to operate as TPAs, which manage claims and administrative functions on behalf of insurers. Applicants must provide key information, including the name of the TPA, tax identification number, and principal office address. Additionally, the form requires details about the business structure, whether it be a corporation, partnership, or proprietorship. A $200 fee must accompany the application, and specific bond requirements are outlined based on the type of services provided. Notably, the form also includes questions regarding the applicant's history with licenses and any affiliations with insurers or plan sponsors. Compliance with all statutory requirements is mandatory, and any changes in information must be reported to the Illinois Department of Insurance within 30 days. Completing the TPA 1 form accurately is crucial for a smooth licensing process and to ensure adherence to state regulations.
What is the Illinois TPA 1 form?
The Illinois TPA 1 form is an application used by third-party administrators (TPAs) to obtain a license from the Illinois Department of Insurance. This form collects essential information about the TPA, including its business structure, responsible individuals, and financial details. It is a critical step for any organization wishing to operate as a TPA in Illinois.
Who needs to fill out the TPA 1 form?
Any organization intending to act as a third-party administrator in Illinois must complete the TPA 1 form. This includes corporations, partnerships, and sole proprietorships. However, it is important to note that a TPA license is not required for those administering fire and casualty funds or claims.
What information is required on the TPA 1 form?
The TPA 1 form requires various details, including the name of the TPA, tax identification number, principal administrative office address, and the type of business organization. Additionally, it asks for information about individuals responsible for the TPA’s operations and any bond requirements. If the TPA operates under an assumed name, a copy of the DBA registration must be attached.
What is the fee for submitting the TPA 1 form?
A fee of $200 is required when submitting the TPA 1 form. This payment must be made via check or money order, made out to the Director of Insurance. It is essential to include this fee to ensure the processing of the application.
What is the bond requirement for TPAs?
Most TPAs must file a surety bond with their application, unless they are contracted with an insurer as an administrator and the plan is fully insured. The bond amount varies based on whether the TPA maintains an Administrative Trust Fund (ATF) or a Claims Administration Services Account (CASA). The bond must be continuous and be in an amount not exceeding $1,000,000.
Can a TPA claim an exemption from the bond requirement?
Yes, a TPA can claim an exemption from the bond requirement if it does not maintain an Administrative Trust Fund or a Claims Administration Services Account. The applicant must indicate this exemption on the form by checking the appropriate box.
What happens if a TPA's license has been denied or revoked in the past?
If any administrator license applied for or issued to the applicant or any responsible individuals has been denied, suspended, revoked, or surrendered, the applicant must disclose this information on the form. A copy of the relevant order must be attached to the application.
Is there a requirement for a written agreement with insurers or plan sponsors?
Yes, the applicant must have written agreements with insurers or plan sponsors as required under specific regulations. If such agreements exist, the applicant must provide details, including names, addresses, and relevant dates. If no agreements are in place, an explanation is necessary.
What should an applicant do if they have questions about completing the TPA 1 form?
If there are any questions or uncertainties regarding the completion of the TPA 1 form, it is advisable to contact the Illinois Department of Insurance directly. They can provide guidance and clarify any aspects of the application process.
Incomplete Information: Failing to fill out all required fields can lead to delays or rejection of the application. Each section must be completed, including the name of the TPA, tax identification number, and address.
Incorrect Fee Submission: The application requires a fee of $200. Submitting the wrong amount or failing to include a check or money order can result in the application being processed incorrectly.
Missing Signature: The form must be signed by an authorized individual. Omitting the signature can cause the application to be considered invalid.
Failure to Attach Required Documents: If the TPA is registered under an assumed name, a copy of the DBA registration must be included. Not attaching necessary documents can lead to complications.
Inaccurate Bond Information: If claiming a bond exemption, the applicant must clearly check the appropriate box and provide accurate information. Misunderstanding the bond requirements can lead to misunderstandings regarding compliance.
State of Illinois
Illinois Department of Insurance
320 W. Washington Street
Springfield, IL 62767-0001
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.
1. Name of TPA
2. Tax or Social Security #
3. Address (number street) of Principal Administrative Office
Telephone # (include Area Code)
4. City
5.State
6. Zip Code
7. Type of business organization (check one)
(
)
Corporation
State of incorporation ________________________________
Year of Incorporation __________
Partnership
Year of formation _____________
Proprietorship
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 _________________________________________________________________________________________
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.
IL446-0177 (Rev. 2/13) IOCI 13-472
TPA-1 (page 1 of 2)
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)
Things to Do:
Things Not to Do:
When applying for a Third Party Administrator (TPA) license in Illinois, several other forms and documents may be required to support your application. Below is a list of commonly used documents that accompany the Illinois TPA 1 form, along with brief descriptions of each.
Ensuring that you have all necessary documents ready can streamline the application process and increase the likelihood of approval. Be thorough and accurate in your submissions to avoid delays.
Misconceptions about the Illinois TPA 1 form can lead to confusion and errors in the application process. Here are eight common misconceptions, along with clarifications:
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