Application For Certificate Of Authority Form printable pdf download

Application For Certificate Of Authority Form

State Office Park South

95 Pleasant Street

Concord, NH 03301

State of New Hampshire

603/271-3176

TDD Access: Relay NH

1-800-735-2964

Department of Labor

FAX: 603/271-6149

George N. Copadis

Labor Commissioner

David M. Wihby

APPLICATION for CERTIFICATE of AUTHORITY

Deputy Labor

Commissioner

THIRD PARTY ADMINISTRATORS

CHAPTER 161

ADMINISTRATOR NAME: ______________________________________________________________

TRADE NAME (if any) __________________________________________________________________

DOMICILE: ___________________________________________________________________________

ADDRESS: ____________________________________________________________________________

______________________________________________________________________________________

CONTACT NAME: _____________________________________________________________________

CONTACT TITLE: ______________________________________________________________________

PHONE: ____________________________________ FEIN # ___________________________________

CONTACT

ADDRESS_____________________________________________________________________________

Note: This department will only correspond with the named contact person. This individual may

be in the company or a contracted person such as a consultant.

Fees

Application Examination

$200.00

Annual Renewal

$100.00

(Due 60 days prior to license expiration)

All checks must be made payable to: New Hampshire Labor Department.

Our review process will not being until fees are paid. New Hampshire law does not allow for the

payment of fees after the issuance of the license.

Application For Certificate Of Authority Form