Application For Certificate Of Authority - New Hampshire Department Of Labor

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State of New Hampshire
Hugh J. Gallen
State Office Park
Spaulding Building
95 Pleasant Street
Concord, NH 03301
Department of Labor
603/271-3176
TDD Access: Relay NH
1-800-735-2964
James W. Craig
FAX: 603/271-6149
Commissioner of Labor
David M. Wihby
Deputy Labor
Commissioner
APPLICATION for CERTIFICATE of AUTHORITY
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 begin until fees are paid. New Hampshire law does not allow for the
payment of fees after the issuance of the license.

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