Article Guide
The Illinois TPA 1 form is a crucial document for anyone looking to operate as a Third Party Administrator (TPA) in the state. This application requires detailed information about the TPA, including its name, tax identification number, and the address of its principal administrative office. Applicants must also specify their business structure, whether it be a corporation, partnership, or proprietorship. Additionally, the form mandates the submission of a surety bond, unless an exemption is claimed, with specific amounts based on the type of funds managed. The application process also involves disclosing any past regulatory actions or criminal convictions related to the individuals responsible for the TPA. It is essential to include information about any agreements with insurers or plan sponsors and to declare any ownership interests in related entities. Completing the TPA 1 form accurately is vital, as it ensures compliance with Illinois insurance laws and facilitates the licensing process for TPAs in the state.
Document Preview
State of Illinois
Illinois Department of Insurance
320 W. Washington Street
Springfield, IL
Third Party Administrator – License Application
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)
4. City
5.State
6. Zip Code
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 ofthe TPA.
Name ________________________________________ Title ____________________________________________
Address _________________________________________________________________________________________
Name ________________________________________ Title ____________________________________________
Address _________________________________________________________________________________________
Name ________________________________________ Title ____________________________________________
Address _________________________________________________________________________________________
If more space is needed, attach a separate sheet listing additional persons.
9.Bond Requirement. Unless the administrator is contracted with the insurer as an adminstrator 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 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 continous 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 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. o
I, ________________________________________________, do not maintain an Administrative Trust Fund (ATF) or a
(Name of Administrator)
Claims Administration Services Account (CASA). Therefore, I claim exemption from the bond requirement for adminstrators as set forth above.
Yes |
No |
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.Are any of the applicant’s books, records, documents or other papers relating to the applicant’s business affairs located, or created by processes or functions located, outside of the United States?
15.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.
16.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 the name(s), address(es) of the ultimate risk bearers pursuant to Section 511.106(d).
17.Has the applicant even 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?
18.Will this license be used to administer any other life, accident and health plans?
19.The applicant and any person listed under No. 8 shall identify any ownership interest of 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 name(s) and address(es) and what interest or affiliation.
________________________________________________________________________________________________
________________________________________________________________________________________________
20.List the names and official positions of all the individuals not listed in No. 8 on page 1 who are members of the boards 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 person with that organization.
____________________________ |
____________________________ |
____________________________ |
____________________________ |
____________________________ |
____________________________ |
____________________________ |
____________________________ |
____________________________ |
____________________________ |
____________________________ |
____________________________ |
____________________________ |
____________________________ |
____________________________ |
If more space is needed, please attach separate sheet listing additional person.
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 with 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.
Form Specifications
| Fact Name | Details |
|---|---|
| Governing Law | The Illinois Third Party Administrator Act governs the TPA-1 form. |
| Application Purpose | The TPA-1 form is used to apply for a license to operate as a third party administrator in Illinois. |
| Fee Requirement | A fee of $200 must be submitted with the application, payable to the Director of Insurance. |
| Exemption Clause | Licensing is not required for administering fire and casualty funds or claims. |
| Bond Requirement | Applicants must file a surety bond unless contracted with an insurer as an administrator. |
| Bond Amounts | Bond amounts vary based on the type of funds managed, with limits up to $1,000,000. |
| DBA Registration | If using an assumed name, a copy of the DBA registration must be attached to the application. |
| Criminal History Disclosure | Applicants must disclose any felony convictions or regulatory actions against them. |
| Written Agreements | Written agreements with insurers or plan sponsors are required under specific conditions. |
| Application Signing | The application must be signed by an authorized officer, principal, or proprietor of the TPA. |
Illinois Tpa 1: Usage Guidelines
Completing the Illinois TPA-1 form is a crucial step for third party administrators seeking to obtain a license. After filling out the form, ensure all required documents are attached and submit it along with the appropriate fee to the Illinois Department of Insurance.
- Print or type all information on the form, except where a signature is required.
- Enter the name of the Third Party Administrator (TPA) in the designated field.
- Provide the Tax Identification Number or Social Security Number.
- Fill in the address of the Principal Administrative Office, including the street number and name.
- Include the telephone number with the area code.
- Indicate the city, state, and zip code of the office.
- Select the type of business organization by checking the appropriate box: Corporation, Partnership, or Proprietorship. If applicable, provide the state of incorporation and year of incorporation or formation.
- List the name, title, and residence address of each person responsible for the conduct of the TPA. If more space is needed, attach an additional sheet.
- Determine the bond requirement and indicate the estimated amounts for contributions, premiums, claims, and claims adjustment expenses.
- If claiming a bond exemption, check the appropriate box and provide the name of the administrator.
- Answer the questions regarding any past license issues, felony convictions, and the location of business records.
- Provide details of any written agreements with insurers or plan sponsors, if applicable.
- Identify any ownership interests or affiliations with plan sponsors or insurers.
- List the names and official positions of individuals not previously mentioned who are part of the governing body or committee.
- Sign the form, certifying that the information provided is accurate and that you are authorized to file the application.
- Attach a check or money order for $200 made payable to the Director of Insurance.
Your Questions, Answered
What is the Illinois TPA 1 form used for?
The Illinois TPA 1 form is an application for a Third Party Administrator (TPA) license in the state of Illinois. This license is necessary for entities that administer health insurance plans or manage claims on behalf of insurers. It ensures that TPAs comply with state regulations and maintain financial responsibility while handling funds related to insurance claims.
What information is required on the TPA 1 form?
The form requires several key pieces of information. Applicants must provide the name of the TPA, its tax or social security number, and the principal administrative office's address and phone number. Additionally, the form asks for details about the business structure (corporation, partnership, or proprietorship) and the individuals responsible for managing the TPA. Information about financial bonds, any prior licensing issues, and affiliations with insurers or plan sponsors must also be included.
Is there a fee associated with the TPA 1 application?
Yes, there is a fee of $200 that must accompany the application. This fee can be paid via check or money order made out to the Director of Insurance. It's important to ensure that this payment is included, as the application will not be processed without it.
What are the bonding requirements for a TPA?
Bonding requirements depend on the type of services the TPA provides. Generally, a surety bond must be filed with the application and maintained while licensed. The bond amount varies based on whether the TPA maintains an Administrative Trust Fund (ATF) or a Claims Administration Services Account (CASA). The bond must cover at least $50,000 or 5% of projected contributions and premiums, up to a maximum of $1,000,000. If a TPA does not maintain either fund, they may claim a bond exemption.
What happens if there are changes in the information provided after submitting the TPA 1 form?
If there are significant changes in the information provided in the application, the TPA is required to notify the Director of Insurance within 30 days. This ensures that the licensing authority has the most current and accurate information regarding the TPA's operations and compliance with state laws.
Common mistakes
-
Incomplete Information: Many applicants forget to fill out all required fields. Each section must be completed, including the name of the TPA, address, and type of business organization. Leaving any section blank can delay the processing of the application.
-
Incorrect Fee Payment: The application requires a fee of $200. Some applicants either forget to include the payment or submit the wrong amount. Always double-check that a check or money order is attached and made out to the Director of Insurance.
-
Missing Attachments: If the TPA operates under an assumed name, applicants must attach a copy of the DBA registration. Failing to include necessary documents can lead to rejection of the application.
-
Not Disclosing Required Information: Questions about prior license issues or felony convictions are crucial. Applicants sometimes overlook these questions or provide incomplete answers. Always provide full disclosure to avoid complications.
Documents used along the form
The Illinois TPA-1 form is a crucial document for those looking to operate as a third-party administrator in the state. However, several other forms and documents are often used alongside it to ensure compliance and proper operation. Below is a list of these essential documents, each playing a significant role in the licensing process and ongoing administration.
- Surety Bond: This document serves as a guarantee that the third-party administrator will fulfill its obligations. It protects clients by ensuring that funds are available to cover claims and administrative expenses.
- DBA Registration: If the TPA operates under a name different from its legal business name, a "Doing Business As" (DBA) registration is required. This document confirms the assumed name is officially recognized.
- Written Agreements with Insurers: These agreements outline the relationship between the TPA and insurers or plan sponsors. They detail the responsibilities and expectations of each party, ensuring clarity in operations.
- Financial Statements: These documents provide a snapshot of the TPA's financial health. They are often required to demonstrate the ability to manage funds responsibly and meet obligations.
- Criminal Background Check: A background check is often necessary to ensure that individuals involved with the TPA have not been convicted of felonies. This helps maintain the integrity of the administration process.
- Board Member List: This document lists all members of the governing body of the TPA. It ensures transparency and allows for accountability in the administration's leadership.
Each of these documents plays a vital role in the licensing and operational processes for third-party administrators in Illinois. By ensuring that all necessary paperwork is in order, TPAs can operate smoothly and maintain compliance with state regulations.
Similar forms
- TPA-2 Form: This form is also used for licensing third-party administrators in Illinois. Like the TPA-1, it requires detailed information about the applicant's business structure and compliance with state regulations.
- Insurance License Application: Similar to the TPA-1, this application is necessary for businesses seeking to operate in the insurance industry. Both forms require proof of financial stability and compliance with state laws.
- DBA Registration Form: If a TPA operates under an assumed name, this form is necessary. It parallels the TPA-1's requirement to attach DBA documentation, ensuring transparency in business operations.
- Surety Bond Application: This document is essential for applicants needing to secure a surety bond. Like the TPA-1, it outlines the financial obligations and protections necessary for operating as a third-party administrator.
- Business Entity Registration: This form registers a business entity with the state. It shares similarities with the TPA-1 in requiring the business structure and formation details for compliance purposes.
- Financial Disclosure Statement: This document requires detailed financial information from the applicant. It is akin to the TPA-1's bond requirements, ensuring that the TPA can meet its financial obligations.
Dos and Don'ts
Filling out the Illinois TPA-1 form can be a straightforward process if you keep a few important tips in mind. Here’s a list of things to do and avoid to ensure your application is submitted smoothly.
- Do print or type all information clearly.
- Do attach the required fee of $200 in the form of a check or money order.
- Do provide accurate and complete information for each section, especially regarding ownership and affiliations.
- Do ensure that any individuals listed in the application have their names and addresses accurately recorded.
- Do double-check that any necessary supporting documents, like DBA registrations, are included.
- Do sign the application and date it before submission.
- Don't leave any sections blank; if something doesn’t apply, indicate that clearly.
- Don't forget to check the box for bond exemption if applicable.
- Don't submit the form without reviewing it for errors or missing information.
- Don't ignore the requirement to notify the Director of Insurance of any significant changes within 30 days.
- Don't assume that a TPA license is not needed for fire and casualty claims without verifying your specific situation.
- Don't submit the application without ensuring that all parties listed are aware of their inclusion.
By following these guidelines, you can help streamline the process and increase the likelihood of a successful application. Good luck!
Misconceptions
When it comes to the Illinois TPA 1 form, there are several misconceptions that can lead to confusion. Understanding these can help ensure a smoother application process for third-party administrators. Here are four common misconceptions:
- A TPA license is always required for all administrators. Many believe that every third-party administrator must have a TPA license. However, this is not the case. A license is not required if the administrator is handling fire and casualty funds or claims.
- Bond requirements apply to all applicants. Some think that every applicant must submit a bond with their application. In reality, there is an exemption available. If an administrator does not maintain an Administrative Trust Fund (ATF) or a Claims Administration Services Account (CASA), they can claim exemption from the bond requirement.
- The application process is overly complicated. While the TPA 1 form may seem lengthy, it is designed to gather essential information clearly and systematically. By following the instructions and providing accurate details, applicants can navigate the process more easily than they might expect.
- All questions on the form must be answered. Some individuals feel pressured to answer every question, even if it does not apply to them. However, if a question is not relevant to your situation, you can simply indicate that it does not apply. This helps streamline the application and avoids unnecessary complications.
By dispelling these misconceptions, applicants can approach the Illinois TPA 1 form with greater confidence and clarity. Understanding the requirements and nuances of the application can lead to a more efficient process.
Key takeaways
Here are some important points to keep in mind when filling out and using the Illinois TPA 1 form:
- Complete all sections: Ensure that every part of the form is filled out completely. Use printed letters or type the information for clarity.
- Fee payment: Attach a check or money order for $200 made out to the Director of Insurance.
- Business structure: Indicate your type of business organization, such as corporation, partnership, or proprietorship. Make sure to include the year of incorporation or formation.
- Bond requirements: Understand that you may need to file a surety bond, depending on your administrative services. This bond protects against financial loss.
- Claim exemptions: If you do not maintain an Administrative Trust Fund (ATF) or a Claims Administration Services Account (CASA), check the box for bond exemption.
- Disclosure of issues: Be honest about any past license denials, suspensions, or criminal convictions. Attach any required documents.
- Keep records accessible: Ensure that your books and records are available and that you have agreements in place with insurers or plan sponsors.
- Signature required: The form must be signed by an authorized individual. Ensure that the date of signing is included.
Filling out the Illinois TPA 1 form accurately is crucial for a smooth application process. Take your time and double-check your information before submission.