Form Il446-0177 - Third Party Administrator- License Application Tpa-1 (Page 2 of 2) in pdf

Yes

11. Has any administrator license applied for or issued to applicant or any person listed under No. 8 on the

reverse side ever been denied, suspended, revoked or surrendered as a remedy for regulatory action? If

"yes," attach a copy of the order.

12. Has the applicant or any persons listed under No. 8 ever been convicted of a felony, or entered a plea of

nolo contendre to a criminal action? If "yes," attach a certified copy of the indictment, judgement and

sentencing order.

13. Is the applicant licensed in its state of domicile?

14. Does the applicant have a written executed agreement(s) with the insurer(s) or plan sponsor(s) as required

under Section 511.106(d)? If "yes," give name and address of each insurer or plan sponsor, execution

date(s) and termination date(s). If "no," explain in detail. Attach a separate sheet.

15. Does the applicant have any written agreement(s) with any insurer or plan sponsor(s) that do not assume or

bear the risk? If "yes," attach a separate sheet with name(s), address(es) of the ultimate risk bearers

pursuant to Section 511.106(d).

16. Has the applicant ever been affiliated with an insurer or plan sponsor which was unable to meet its claim or

other financial obligations on a current basis from the assets of the plan?

17. Will this license be used to administer any other than life, accident and health plans?

18. The applicant and any person listed under No. 8 shall identify any ownership interest or affiliation of any kind with any plan sponsor

or insurer which is responsible directly or through reinsurance for providing benefits to any plan for which the applicant provides

services as an administrator. List the name(s) and address(es) and what interest or affiliation.

19. List the names and official positions of all the individuals not listed in No. 8 on page 1 who are members of the board of directors,

board of trustees, executive committee, or other governing board or committee, officers in the case of a corporation, and the partners

or members in the case of a partnership or association. If any person listed is not a natural person, list the directors, members, and

responsible persons within that organization.

Name

Title or Position

Address

If more space is needed, please attach separate sheet listing additional persons.

I, ______________________________________________, being duly sworn and on oath, state that I am an officer/principal/

proprietor of the above listed TPA, and that I am authorized and directed to file this application for a license to operate as a

third party administrator in the State of Illinois. If granted a license, the TPA agrees that it will comply with all valid and legal

requirements of statutes and the Director of Insurance insofar as they relate to the operation of applicant as a TPA. The TPA

also specifically agrees that it will notify the Director of Insurance of any significant change in information required in this

application or otherwise within 30 days, and that any service of process sent to the above indicated address will be deemed

to have been served on the TPA.

We hereby apply for a license to operate a third party administrator in the State of Illinois.

_____________________________________________

Date of Signing

Signature of Principal

Important Notice: Disclosure of this information is required under the Illinois Revised Statutes' insurance laws. Failure to provide

this information will result in this form not being processed. This form has been approved by the Forms Management Center.

IL446-0177 (Rev. 5/09)

TPA-1 (page 2 of 2)

Form Il446-0177 - Third Party Administrator- License Application Tpa-1 Page 2