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TPA Project Readiness Form

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Compliance Specialty (TPA) Attestation Form

This form is a prerequisite before initiating a Project Cost Analysis (PCA) or engaging in discussions regarding a Third Party Administrator (TPA) licensing project. The data provided herein serves the sole purpose of evaluating whether ReSource Pro can proceed with the intended specialty licensing project. It is crucial to emphasize that this information is exclusively utilized to assess the readiness of the client to meet the criteria and regulatory standards essential for the desired TPA licenses. By completing this form, both parties can ascertain the feasibility of commencing the project without encountering obstacles due to unmet requirements, thereby optimizing time efficiency for all involved stakeholders.

* If you cannot finish this form in one session, scroll to the bottom to the Save & Continue option.
Do you have audited financials for the previous 3 years?(Required)
If Yes, then proceed. If No, it is recommend you wait to start the licensing process until you do. Most states require this before they’ll issue a TPA license.
How long have you been acting as a TPA?(Required)
Have you reached the 100 certificate holder threshold?(Required)
(Check all that apply)
What lines of business will you offer?(Required)
Domicile State Information
Are you licensed in your domicile/resident state?(Required)
If not licensed in domicile state, does your domicile state offer TPA Licenses?
* If you cannot finish this form in one session, scroll to the bottom to the Save & Continue option.
Check below if domicile state is:
Only select one.
Business Transaction Details
Is the TPA intending to directly solicit insurance contracts or otherwise act as an insurance producer?(Required)
Are you soliciting business as an administrator (see description below) in non-resident states?(Required)
* If you cannot finish this form in one session, scroll to the bottom to the Save & Continue option.
Criteria for exemptions are (all must be met):
*States offering this exemption are AK, DE, IN, KS, ME, NC, NH, NM, OR, RI, SD, & WV – all criteria must be met.

List of Required Items Needed Before Project Can Start:

  • Bylaws (Inc) or Operating Agreement (LLC) – Must be signed by the Secretary, certified true and correct as of date signed, and sealed.                 
  • Statement of Employees – Staffing levels and activities in this state and nationwide, details applicants’ capability for providing sufficient number of experienced and qualified personnel in areas of claims processing, recordkeeping, and underwriting.
  • Resumes for key people performing as TPA – Resumes for each qualified person; must list full name, resident address, position of employment, licensing history, qualifications and experience relating to the work being performed. Must identify whether employee or contractor.                                                                          
  • Certified financial statement for the prior two years by a CPA, certified by officer if in business longer than 2 years.       
  • Financial statement for the prior year or any months in current fiscal year, attested by company officer and notarized – if not in business longer than 2 years, include statement indicating that.  
  • Certified financial statement for the prior three years (MN, TX only)
  • Business Plan – The detailed business plan must include: history, products and services, staffing levels, activities proposed in this state and nationwide, applicant’s capability for providing a sufficient number of experienced and qualified personnel in the areas claims processing, record keeping and underwriting. Total number of insureds, Name of plan sponsor and affiliations, name of companies receiving services, type of services, type of business being serviced, lines of business for each.                                                      
  • Plan of Operation – Plan of operation must include: the number of officers, managers and supervisors and the responsibilities of each, the number of officers, managers and supervisors and the responsibilities of each, a list of departments of the applicant and the main function(s) of each department, the number of employees per department, a brief description of the claims paying system which indicates if the system is automated or manual, a brief description of the funding arrangements used on plans administered, unauthorized or fraudulent payment of claims or other misuse of plan funds.  
  • Organization Chart – A detailed description of the corporate organizational/ownership structure of the applicant, its parent company, and all affiliates. This description should include a chart showing the ownership percentages for any persons owning 10 percent or more of the applicant and all affiliated entities up to and including the ultimate controlling person. The chart must include the state of domicile and the Federal Employer Identification Number (FEIN) for each person. If there is no person who owns, directly or indirectly, 10 percent or more of the applicant then you must provide a statement to that effect in lieu of this exhibit.
  • Verification of TPA applicant’s “Owners” respective ownership percentage (stock certs or ownership agreements)
  • Documentation of established Fiduciary Bank Account – Name of bank, with complete address and account numbers, balance, type, purpose of account, and parties to the account.
  • Must provide a letter of good standing from a financial institution. 
  • Documentation that Separates Claims Paying Account will be established for each insurer or letter stating that the insurer is handling payment.
  • Administrative Services & Commissions Agreement
  • Summary of Insurance Policies & 1 sample service contract
  • E&O Policy at least $100,000 
  • Statement of duties to be performed by TPA on behalf of the insured.
  • List of accounts administered and NAIC company numbers, each amount handled in the state of application, annually. Show separate amount for premium collected and claims paid.
  • Crime Policy
  • Sample Carrier Contract

State Specific Requirements

  • DE must be applied for as resident if, state of formation or principal place of business does not have regulations pertaining to TPA.
  • ID must be applied for as resident, unless resident of/or home state license is DE, IN, FL, KS, MO, NH, WV. 
  • IN must be applied for as resident, unless resident of/or home state license is AK, DE, FL, ID, KS, MO, NH, NJ, WV.
  • KS must be applied for as resident, unless resident of/or home state license is AK, DE, FL, ID, MO, NH, NJ, WV. 
  • MN must have a Licensed Resident Adjuster in MN to obtain TPA-P/C license.

According to the NAIC TPA Model Act, the definition of a Third Party Administrator is as follows:

“Third party administrator” or “TPA” means a person who directly or indirectly underwrites, collects charges, collateral or premiums from, or adjusts or settles claims on residents of this state, in connection with life, annuity, health, stop-loss or workers’ compensation coverage, except that a person shall not be considered a TPA if that person’s only actions that would otherwise cause it to be considered a TPA are among the following: (1) A person working for a TPA to the extent that the person’s activities are subject to the supervision and control of the TPA; (2) An employer administering its employee benefit plan or the employee benefit plan of an affiliated employer under common management and control, except that workers’ compensation shall not be considered as an “employee benefit plan;” NAIC Model Laws, Regulations, Guidelines and Other Resources—October 2011 © 2011 National Association of Insurance Commissioners GL-1090-5 (3) The administration of a bona fide employee benefit plan established by an employer or an employee organization, or both, for which the insurance laws of this state are preempted pursuant to the Employee Retirement Income Security Act of 1974, as the act existed on [an appropriate recent date should be selected]; (4) A workers’ compensation self-insurer that has been approved by [agency responsible for the approval of workers’ compensation self-insurance] or an employer otherwise authorized by law to administer its workers’ compensation obligations to its employees or co-employees, while administering workers’ compensation benefits for its employees or co-employees; (5) A union administering a benefit plan on behalf of its members; (6) An insurer administering insurance coverage for its policyholders, subscribers or certificate holders, or those of an affiliated insurer under common management and control; (7) An insurer directly or indirectly underwriting, collecting charges, collateral or premiums from, or adjusting or settling claims for life, annuity, health or stop-loss insurance on behalf of a client that is not a policyholder, subscriber or certificate holder, and that has its United States headquarters or principal location of business in a jurisdiction in which the insurer is licensed to write that coverage; (8) An insurer directly or indirectly underwriting, collecting charges, collateral or premiums, or adjusting or settling claims for life, annuity, health or stop-loss insurance, provided that the insurer is licensed in this state to write that line of insurance coverage; (9) An insurance producer selling insurance or engaged in related activities within the scope of the producer’s license, except that this shall not include the adjusting or settling of workers’ compensation claims; (10) A creditor acting on behalf of its debtors with respect to insurance covering a debt between the creditor and its debtors; (11) A trust and its trustees and agents acting pursuant to such trust established in conformity with 29 U.S.C. Section 186; (12) A trust exempt from taxation under Section 501(a) of the Internal Revenue Code and its trustees acting pursuant to such trust, or a custodian and the custodian’s agents acting pursuant to a custodian account which meets the requirements of Section 401(f) of the Internal Revenue Code; (13) A credit union or a financial institution that is subject to supervision or examination by federal or state banking authorities, or a mortgage lender, when collecting or remitting premiums to licensed insurance producers or to limited lines producers or authorized payors in connection with loan payments; (14) A credit card issuing company advancing or collecting insurance premiums or charges from its credit card holders who have authorized collection; (15) An individual adjusting or settling claims in the normal course of that individual’s practice or employment as an attorney at law and who does not collect charges or premiums in connection with insurance coverage; (16) A person licensed as a managing general agent in this state when acting within the scope of that license; or (17) A business entity licensed pursuant to [insert statutory reference] to adjust workers’ compensation loss claims, but only if that entity does not receive or manage funds from employers or other persons whose workers’ compensation claims are being adjusted and does not manage or control related funds of the payor that is ultimately responsible for the claims.

Name (must be an Officer)(Required)
By entering your name and signature below, you acknowledge that you have filled out this form to the best of your ability, read an understand the NAIC TPA Model Act, and will be able to supply all the required items necessary for ReSource Pro to begin this TPA project.
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