Form Il446-0177 - Third Party Administrator- License Application Tpa-1
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2Illinois Department of Insurance
320 West Washington Street
Springfield, IL 62767-0001
State of Illinois
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)
6. Zip Code
4. City
5. State
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 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 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 continuous 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 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
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.
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 (Rev. 5/09)
TPA-1 (page 1 of 2)
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