Form Il 446-0177 - State Of Illinois Third Party Administrator-License Application Tpa-1 - Department Of Financial And Professional Regulation
Download a blank fillable Form Il 446-0177 - State Of Illinois Third Party Administrator-License Application Tpa-1 - Department Of Financial And Professional Regulation in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Form Il 446-0177 - State Of Illinois Third Party Administrator-License Application Tpa-1 - Department Of Financial And Professional Regulation with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
2Illinois Department of Financial and Professional Regulation
Division of Insurance
320 W. Washington Street
State of Illinois
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 No.
5. State
4. City
6. Zip Code
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 of
the TPA.
Name___________________________________________ Title_________________________________________________
___________________________________________________________________________________________________________
Address
Name____________________________________________ Title________________________________________________
Address
__________________________________________________________________________________________________________
Name____________________________________________ Title_____________________________________________
______________________________________________________________________________________________________
Address
If more space is needed, attach separate sheet listing additional persons.
9. Bond Requirement. Unless the administrator is contracted with the insurer as an administrator and the plan is fully in-
sured 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 in 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 continu-
ous 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 Ser-
vices 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 to 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 ex
ceed $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.
I,
do not maintain an Administrative Trust Fund (ATF) or a Claims
(Name of Administrator)
Administration Services Account (CASA). Therefore, I claim exemption from the bond requirement for administrators as set forth
above.
IL446–0177 (07/04)
ADVERTISEMENT
0 votes
Related Articles
Related forms
Form Il486-2226 - Fingerprint Consent Form Medical - Cannabis Dispensing Organization Applicant - Illinois Department Of Financial And Professional Regulation
Legal
Certification/clearance Request Form - Illinois Department Of Financial And Professional Regulation
Legal
State Of Florida Department Of Business And Professional Regulation Division Of Pari-mutuel Wagering
Legal
Form Ab&t - Out Of State Cigarette Importer's Detail Report - Department Of Business And Professional Regulation
Legal
Form Ab&t - Instate Cigarette Importers Detail Report - Department Of Business And Professional Regulation
Legal
Related Categories
Parent category: Legal