Fillable Form Si Tpa - Application For Third Party Administrator Permit printable pdf download

OKLAHOMA WORKERS’ COMPENSATION COMMISSION

1915 NORTH STILES AVENUE

OKLAHOMA CITY, OK 73105

(405) 522-3222 or In-State Toll Free (855) 291-3612

APPLICATION FOR THIRD PARTY ADMINISTRATOR PERMIT

Date__________________________________

The undersigned, a company providing Third-Party Administrative Services to Own Risk employers and/or Group

Self-Insurance Associations, hereby applies for permission to act as an approved Third-Party Administrator. To

enable the Workers' Compensation Commission to determine the applicant’s ability to provide these services, said

applicant hereby states the following:

1. TPA Name ________________________________________________________________________________

2. Desired effective date (application should be submitted 30 days in advance) ___________________________

3. TPA # (if a renewal applicant) _________________________________________________________________

4. Name of Parent Company, if applicable _________________________________________________________

5. Home office address, phone number & e-mail address _____________________________________________

__________________________________________________________________________________________

6. Oklahoma office address, phone number & e-mail address __________________________________________

__________________________________________________________________________________________

Years in business: Nationally _______________________ In Oklahoma _______________________________

8. Please include the following items with the application:

A nonrefundable $1,000 application fee, payable to the Oklahoma Workers’ Compensation Commission.

b. Audited financial statements for the most recent fiscal year, including a balance sheet, statement of

income, statement of cash flows, and notes. Financial statements may be submitted via email to

InsuranceDepartment@wcc.ok.gov

or via a cd delivered with the application.

A list of all claims adjusters on staff. Please include a photocopy of the current Oklahoma license for each

adjuster.

d. A list of all claims managers or equivalent supervisory personnel. Please include a brief resume for each

manager.

A description of how service fees are determined.

Services performed by the applicant. If services are provided other than claims adjusting, such as safety

consulting, marketing or accounting functions, please provide a brief resume of the principal employee(s)

providing these services.

A description of how client funds are handled for payment of claims.

h. A copy of the most recent triennial independent audit performed on the applicant.

A copy of the Service Organization Controls (SOC) 1 report pursuant to the statement on standards for

attestation engagements (SSAE) No. 16, resulting from the most recent independent audit.

A description of the applicant’s policy for setting reserves.

Form – SI TPA

Page 1 of 2

Rev. 09-21-15

Form Si Tpa - Application For Third Party Administrator Permit