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Blank Ohio Ins3213 PDF Form

The Ohio Ins3213 form is a crucial document for business entities seeking to apply for or renew their Third Party Administrator (TPA) license in Ohio. This form collects essential information about the business, including its ownership, compliance history, and insurance coverage. Completing this form accurately is vital for maintaining compliance with state regulations, so make sure to fill it out by clicking the button below.

Article Guide

The Ohio Ins3213 form is a crucial document for business entities seeking to obtain or renew a Third-Party Administrator (TPA) license in the state of Ohio. This form, overseen by the Ohio Department of Insurance, requires applicants to provide detailed information about their business structure, including the name, address, and federal employer identification number (FEIN). It also asks for essential licensing details, such as the Ohio license number and the National Producer Number (NPN). Applicants must indicate whether they are applying for a resident or non-resident license and disclose affiliations with financial institutions. The form includes sections dedicated to demographic information and background questions, which assess the legal history of the business entity and its key personnel. Notably, it inquires about any past misdemeanor or felony convictions, administrative proceedings, and compliance with insurance laws. Additionally, the form mandates that applicants provide proof of necessary insurance coverage, including fidelity bonds and professional liability insurance, ensuring that they meet the regulatory standards set forth by Ohio law. Completing the Ins3213 form accurately is essential for maintaining compliance and securing the right to operate as a TPA in Ohio.

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Judith L. French, Director

Check appropriate boxes for license requested:

(Please Print or Type)

Resident License

Non-Resident License

Identify Home State:

Identify Home State License #:

Demographic Information

1Business Entity’s Name

2FEIN

3Ohio License Number

4National Producer Number (NPN)

5 Is the business entity affiliated with a financial institution/bank?

Yes

6Business Address

7City

8State

9Zip or Foreign Country

10Phone Number (include extension)

11Fax Number

12Business E-Mail Address

13Business Web Site Address

14Mailing Address

15P.O. Box

16City

17State

18Zip or Foreign County

Designated/Responsible Licensed Producer

19Identify at least one Designated/Responsible Licensed Producer responsible for the business entity’s compliance with the insurance laws, rules, and regulations of this state:

Name	SSN	NPN
Name	SSN	NPN
Name	SSN	NPN
Name	SSN	NPN

Background Questions

20
1a. Has the business entity or any owner, partner, officer or director of the business entity, or member or manager of a limited liability company		Yes	No
been convicted of, or is currently charged with, committing a MISDEMEANOR or had a judgment withheld or deferred for a
MISDEMEANOR which has not been previously reported to this insurance department?
You may exclude the following misdemeanor convictions or pending misdemeanor charges: traffic citations, driving under the influence
(DUI), driving while intoxicated (DWI), driving without a license, reckless driving, or driving with a suspended or revoked license.
You may also exclude juvenile adjudications (offenses where you were adjudicated delinquent in a juvenile court).
1b. Has the business entity or any owner, partner, officer or director of the business entity, or member or manager of a limited liability company		Yes	No
been convicted of, or is currently charged with, committing a FELONY or had a judgment withheld or deferred for a FELONY which has
not been previously reported to this insurance department?
You may also exclude juvenile adjudications (offenses where you were adjudicated delinquent in a juvenile court).
If you have a felony conviction involving dishonesty or breach of trust, have you applied for written consent to engage in the business of	N/A	Yes	No
insurance in your home state as required by 18 USC 1033?
If so, was consent granted? (Attach copy of 1033 consent approved by home state.)	N/A	Yes	No
1c. Has the business entity or any owner, partner, officer or director of the business entity, or member or manager of a limited liability company		Yes	No
been convicted of, or is currently charged with a MILITARY OFFENSE which has not been previously reported to this insurance
department?

NOTE: For Questions 1a, 1b, and 1c, “Convicted” includes, but is not limited to, having been found guilty by verdict of a judge or jury, having entered a plea of guilty or nolo contendere or no contest, or having been given probation, a suspended sentence, or a fine.

If you answered “Yes” to any of the above questions (1a, 1b, or 1c), you must attach to this application:

a)a written statement explaining the circumstances of each incident,

b)a copy of the charging document, and

c)a copy of the official document, which demonstrates the resolution of the charges or any final judgment.

INS3213 (Rev. 02/2021)

Page 1 of 3

Ohio Department of InsuranceBUSINESS ENTITY TPA LICENSE RENEWAL/CONTINUATION

Background Questions (continued)

2. Has the business entity or any owner, partner, officer or director, or manager or member of a limited liability company, been named or

Yes

involved as a party in an administrative proceeding regarding any professional or occupational license or registration, which has not been previously reported to this state?

“Involved” means having a license censured, suspended, revoked, canceled, terminated; or, being assessed a fine, placed on probation or surrendering a license to resolve an administrative action. “Involved” also means being named as a party to an administrative or arbitration proceeding, which is related to a professional or occupational license. “Involved” also means having a license application denied or the act of withdrawing an application to avoid a denial. You may exclude terminations due solely to noncompliance with continuing education requirements or failure to pay a renewal fee.

If “Yes”, you must attach to this application:

a)a written statement identifying the type of license; identifying all parties involved (including their percentage of ownership, if any) and explaining the circumstances of each incident,

b)a copy of the Notice of Hearing or other document that states the charges and allegations, and

c)a copy of the official document which demonstrates the resolution of the charges or any final judgment.

3.	Does the TPA hold a fidelity bond or other comparable insurance policy coverage for all employees as required by R.C. 3959.11 and	Yes	No
	OAC 3901-8-05 (D) (5)?
	If “Yes”, provide a copy of bond or insurance policy coverage. Make sure documentation includes the name of the carrier, policy number
	and effective dates.
4.	Does the TPA carry any type of professional liability and/or E&O insurance for TPA activities as required by ERISA?	Yes	No
	If “Yes”, provide proof of coverage or bond. Make sure documentation includes the name of the carrier, policy number and effective dates.
5.	Do you understand that any required bond, insurance policy, professional liability and E&O insurance policy must be maintained for	Yes	No
	the duration of the licensure period?

6.Will the TPA’s records continue to be maintained in accordance with the requirements of OAC 3901-8-05 (L) and (M)? If the

	answer to any of the questions below is “No”, then attach a letter stating how those records are maintained.
	a)	Records reflect all administered transactions?		Yes	No
	b)	Detailed preparation or journalizing and posting of books and records are maintained?		Yes	No
	c)	Records are maintained throughout the term of the administration agreement?		Yes	No
	d)	All disbursement records contain the information required by R.C. 3959.15 (E)-(H)?		Yes	No
	e)	Annual reports are required to be filed with insurers and plan sponsors within 90 days of the end of each fiscal year of the plan?		Yes	No
	f)	Return premiums or contributions are paid to insurer or plan sponsors within 30 days of receipt?		Yes	No
7.	Since the last application or renewal have any Excess Insurers (Stop-Loss Carriers) or Managing General Underwriters approved the TPA to			Yes	No
	administer claims for plans using their stop-loss products?
	If “Yes”, provide the names and contact information for each one on a separate document.
8.	Since the last application or renewal has the TPA been licensed as a Managing General Agent?			Yes	No
	If “Yes”, provide a name of the States and license status on a separate document.
9.	What type(s) of claims will the TPA administer or plan to administer within the next year in this state?
	(Must check at least one option – Select all appropriate options that apply)
		Traditional self-insured employee benefit plans	Government self-insured employee benefit plans
		Preferred Provider Org. (PPO)	Fully insured employee benefit plans
		Prescription drug claims	Provider billing processing
		Life insurance claims	Medical/Managed care
		Disability insurance claims	Other, attach description on a separate document.
		Dental claims
10. How does the TPA handle plan sponsor and insurer funds?
	(Must check at least one option – Select all appropriate options that apply)
		Accounts are owned by the insurance company
		Plan sponsor owns accounts/TPA has check writing ability
		TPA has a separate fiduciary account(s) for plan sponsor & insurer funds
		OTHER: Attach a letter of explanation.
11. Does the applicant understand that the TPA and its officers shall be responsible for the supervision of the actions of any and all personnel				Yes	No
	and subcontractors who adjust or settle claims on behalf of the applicant according to OAC 3901-8-05 (E)(3)?

Applicant’s Signature:

Ohio Department of InsuranceBUSINESS ENTITY TPA LICENSE RENEWAL/CONTINUATION

Background Questions (continued)

12.	Does the applicant understand that the TPA may not commingle among its personal assets, or draw against for its own purposes, any	Yes	No
	monies or contributions of a plan sponsor or plan participant according to OAC 3901-8-05 (H)(1)?
13.	Have there been any changes of officers, directors, partners, members or trustees, or any change of shareholders or other owners or	Yes	No
	members holding 5% or more ownership in the TPA or change of business address that has not been previously reported to the Department
	as required by OAC 3901-8-05(D)(5)?
	If “Yes”, include the Department’s document for business entity changes.
14.	Is the TPA operating as a Pharmacy Benefit Manager (PBM)?	Yes	No
14.	Is the TPA operating as a Pharmacy Benefit Manager (PBM)?

Applicant’s Certification and Attestation

On behalf of the business entity or limited liability company, the undersigned owner, partner, officer or director of the business entity, or member or manager of a limited liability company, hereby certifies, under penalty of perjury, that:

1.All of the information submitted in this application and attachments is true and complete and I am aware that submitting false information or omitting pertinent or material information in connection with this application is grounds for license or registration revocation and may subject me and the business entity or limited liability company to civil or criminal penalties.

2.Unless provided otherwise by law or regulation of the jurisdiction, the business entity or limited liability company hereby designate the Commissioner, Director or Superintendent of Insurance, or other appropriate party in each jurisdiction for which this application is made to be its agent for service of process regarding all insurance matters in the respective jurisdiction and agree that service upon the Commissioner, Director or Superintendent of Insurance, or other appropriate party of that jurisdiction is of the same legal force and validity as personal service upon the business entity.

3.The business entity or limited liability company grants permission to the Commissioner, Director or Superintendent of Insurance, or other appropriate party in each jurisdiction for which this application is made to verify information with any federal, state or local government agency, current or former employer, or insurance company.

4.Every owner, partner, officer or director of the business entity, or member or manager of a limited liability company, either (a) does not have a current child-support obligation, or (b) has a child-support obligation and is currently in compliance with that obligation.

5.I authorize the jurisdictions to give any information concerning me, as permitted by law, to any federal, state or municipal agency, or any other organization and I release the jurisdictions and any person acting on their behalf from any and all liability of whatever nature by reason of furnishing such information.

6.I acknowledge that I understand and will comply with the insurance laws and regulations of the jurisdictions to which I am applying for licensure/registration.

7.For Non-Resident License Applications, I certify that I am licensed and in good standing in my home state/resident state for the lines of authority requested from the non-resident state.

8.I hereby certify that upon request, I will furnish the jurisdiction(s) to which I am applying, certified copies of any documents attached to this application or requested by the jurisdiction(s).

Must be signed by an officer, director, or partner of the business entity, or member or manager if a limited liability company who has authority to act on behalf of the business entity:

Signature

Type or Print Name

Title

Address

Date

Social Security Number

City

State

Zip

Application Attachments

22The following attachments must accompany the application; otherwise the application may be returned unprocessed or considered deficient.

1.Non-refundable fee (check or money order) made payable to the “State of Ohio Treasurer” in the amount of $300.00;

2.Provide proof of fidelity bond or other comparable insurance policy coverage for all employees as required by R.C. 3959.11 and OAC 3901-8-05 (D)(5). (Documentation must include the name of the carrier, policy number and effective dates.)

3.Provide proof of professional liability insurance coverage and/or E&O insurance as required by ERISA. (Documentation must include the name of the carrier, policy number and effective dates.); and

4.If necessary, any required supporting details or documents.

Requirements for Licensure

1.All business entity TPA applicants must be registered with the Ohio Secretary of State.

2.Non-Resident TPA applicants must be registered with the home state Secretary of State.

INS3213 (Rev. 02/2021)

Page 3 of 3

➤ PDF File

Form Specifications

Fact Name	Description
Purpose	The Ohio Ins3213 form is used for business entities to apply for or renew a Third Party Administrator (TPA) license in Ohio.
Governing Laws	This form is governed by Ohio Revised Code (R.C.) 3959.11 and Ohio Administrative Code (OAC) 3901-8-05.
Fee Requirement	A non-refundable fee of $300.00 must accompany the application, payable to the “State of Ohio Treasurer.”
Attachments	Applicants must provide proof of fidelity bond and professional liability insurance, along with any other required documents.

Ohio Ins3213: Usage Guidelines

Completing the Ohio Ins3213 form is a crucial step in the process of obtaining or renewing a business entity's Third Party Administrator (TPA) license. This form gathers essential information about the business, its owners, and its compliance with state regulations. Properly filling out the form ensures that the application is processed smoothly and efficiently.

Identify License Type: Check the appropriate box for either Resident License or Non-Resident License.
Home State Information: Fill in your home state and its license number.
Demographic Information: Provide the business entity’s name, FEIN, Ohio license number, and National Producer Number (NPN).
Affiliation: Indicate whether the business entity is affiliated with a financial institution or bank by checking 'Yes' or 'No.'
Contact Information: Enter the business address, city, state, zip code or foreign country, phone number (including extension), fax number, business email address, and website address.
Mailing Address: If different from the business address, fill in the mailing address, P.O. Box, city, state, and zip code or foreign country.
Designated Producer: Identify at least one designated or responsible licensed producer, providing their name, Social Security Number (SSN), and NPN.
Background Questions: Answer questions regarding any misdemeanors, felonies, military offenses, administrative proceedings, fidelity bonds, and insurance policies. Attach required documentation if applicable.
Claims Administration: Specify the types of claims the TPA will administer and how funds will be handled.
Compliance Understanding: Confirm your understanding of responsibilities regarding supervision, record maintenance, and compliance with insurance laws.
Changes in Business Structure: Disclose any changes in ownership or business address that have not been reported previously.
Applicant’s Certification: Read and sign the certification section, ensuring all information is accurate and complete.
Attachments: Include the required attachments, such as the non-refundable fee, proof of fidelity bond, proof of professional liability insurance, and any additional documents necessary.

After completing the form and gathering all necessary documents, review everything carefully to ensure accuracy. Then, submit the application along with the required fees to the Ohio Department of Insurance. This will initiate the review process for your TPA license. Be prepared to respond to any follow-up questions or requests for additional information that may arise during the review.

Your Questions, Answered

What is the purpose of the Ohio Ins3213 form?

The Ohio Ins3213 form is used for applying for a Third Party Administrator (TPA) license or for renewing an existing license in Ohio. This form collects essential information about the business entity, including its structure, compliance with insurance laws, and details about designated licensed producers. Completing this form accurately is crucial for ensuring that the application is processed efficiently and meets all regulatory requirements.

Who needs to fill out the Ohio Ins3213 form?

Any business entity seeking to operate as a Third Party Administrator in Ohio must fill out this form. This includes both resident and non-resident applicants. Additionally, if there have been changes in ownership, management, or business structure since the last application or renewal, the form must be updated accordingly. It is essential for all parties involved in the business, including owners and officers, to be aware of their responsibilities and to provide accurate information.

What are the key sections of the form that applicants should pay attention to?

Applicants should focus on several key sections of the Ohio Ins3213 form. First, the demographic information section requires basic details about the business entity, such as its name, address, and identification numbers. Next, the background questions section addresses any legal issues or administrative proceedings that may affect the entity's ability to obtain a license. Finally, the applicant's certification and attestation section is crucial, as it confirms that all information provided is truthful and complete, which is vital for compliance with state regulations.

What attachments are required when submitting the Ohio Ins3213 form?

When submitting the Ohio Ins3213 form, applicants must include several attachments to ensure their application is complete. These include a non-refundable fee of $300, proof of fidelity bond or comparable insurance coverage for employees, and proof of professional liability insurance coverage or errors and omissions (E&O) insurance. If applicable, any additional supporting documents must also be included. Failing to provide these attachments may result in the application being returned or considered deficient.

Common mistakes

Inaccurate Business Entity Information: Failing to provide the correct name of the business entity can lead to delays or rejection of the application. Ensure that the name matches exactly as registered with the Ohio Secretary of State.
Missing Identification Numbers: Omitting the FEIN, Ohio License Number, or National Producer Number (NPN) can cause processing issues. Double-check that these numbers are accurate and included.
Incomplete Demographic Information: Leaving out any required demographic details, such as business address or contact information, may result in the application being returned. All sections must be filled out completely.
Incorrectly Answering Background Questions: Misunderstanding or misrepresenting answers to questions about criminal history can have serious consequences. Take time to read each question carefully and answer truthfully.
Failing to Attach Required Documentation: Not including necessary documents, such as proof of fidelity bond or insurance, can lead to application delays. Ensure all required attachments are included before submission.
Neglecting to Sign the Application: An unsigned application is not valid. Make sure that the application is signed by an authorized person with the appropriate title.
Ignoring the Application Fee: Submitting the application without the required non-refundable fee of $300 can result in the application being processed incorrectly. Always include the payment with your submission.
Overlooking Changes in Business Structure: Failing to report any changes in ownership or business structure can create compliance issues. Keep the application updated with the latest information.
Not Understanding Licensing Requirements: Not being aware of the specific requirements for licensure can lead to mistakes. Review the guidelines thoroughly to ensure compliance with Ohio regulations.

Documents used along the form

The Ohio Ins3213 form is essential for business entities seeking a Third Party Administrator (TPA) license. Along with this form, several other documents may be required to ensure compliance with state regulations. Below is a list of commonly used forms and documents that accompany the Ohio Ins3213 form.

Fidelity Bond Documentation: This document provides proof of a fidelity bond or comparable insurance policy for all employees, as mandated by Ohio law. It should include the name of the insurance carrier, policy number, and effective dates.
Professional Liability Insurance Proof: Evidence of professional liability insurance coverage or Errors and Omissions (E&O) insurance is required. This documentation must also detail the insurance carrier, policy number, and effective dates.
Background Check Results: A summary of any criminal convictions or administrative actions involving the business entity or its key personnel. This information is crucial for assessing eligibility for licensure.
Business Registration Confirmation: Verification that the business entity is registered with the Ohio Secretary of State. This is a prerequisite for obtaining a TPA license.
Child Support Compliance Statement: A declaration confirming whether any owners or key personnel have a current child support obligation, along with compliance status.
Change of Business Structure Document: If there have been any changes in ownership or structure since the last application, documentation reflecting these changes must be provided.
Supporting Documents for Claims Administration: A detailed description of the types of claims the TPA intends to administer, along with any relevant supporting documents.

Ensuring all these documents are prepared and submitted correctly will facilitate a smoother application process for the TPA license. Proper documentation helps demonstrate compliance with Ohio's insurance regulations and supports the business entity's credibility in the industry.

Similar forms

Ohio Ins3210 Form: Similar to the Ins3213, this form is used for applying for a business entity insurance license in Ohio. It requires demographic information and background questions related to compliance and legal history.
Ohio Ins3211 Form: This form is for individual insurance agent licensing in Ohio. Like the Ins3213, it collects personal and professional information, including any legal issues that may affect eligibility.
Ohio Ins3212 Form: This is a renewal application for individual insurance licenses. It parallels the Ins3213 in its need for updated demographic and compliance information.
National Producer Number (NPN) Application: Similar to the Ins3213, this application collects personal and business information to assign a unique identification number for insurance producers across states.
Insurance Agency License Application: This document is used for agencies seeking licensure. It shares the same requirement for background checks and compliance documentation as the Ins3213.
TPA Compliance Form: This form ensures that Third Party Administrators (TPAs) adhere to state regulations. It mirrors the Ins3213 in its focus on compliance and operational transparency.
Insurance Company Application: This application is for entities seeking to operate as insurance companies. It includes similar background questions and compliance checks as found in the Ins3213.
Adjuster License Application: This document is for individuals seeking to become licensed adjusters. It shares the same focus on legal history and compliance with insurance laws as the Ins3213.
Financial Institution License Application: This form is used by financial institutions seeking to engage in insurance activities. It requires similar demographic and compliance information as the Ins3213.
Producer License Renewal Application: This document is for renewing an insurance producer license. Like the Ins3213, it includes background checks and compliance questions to ensure continued eligibility.

Dos and Don'ts

When filling out the Ohio Ins3213 form, it's important to follow specific guidelines to ensure your application is processed smoothly. Here’s a list of what you should and shouldn't do:

Do print or type all information clearly to avoid any misinterpretations.
Do check the appropriate boxes for the license type you are requesting.
Do provide accurate demographic information, including your business entity’s name and address.
Do attach all required documentation, such as proof of insurance and fidelity bonds.
Do ensure that all designated licensed producers are listed with their correct information.
Don't omit any background questions; failing to answer them can lead to delays.
Don't provide false information; this can result in penalties or revocation of your license.
Don't forget to sign the application; an unsigned application may be considered incomplete.
Don't ignore the requirement for a non-refundable fee; ensure it is included with your submission.

Misconceptions

Misconception 1: The Ohio Ins3213 form is only for resident businesses.

This form is applicable to both resident and non-resident businesses. Non-resident applicants must identify their home state and provide relevant license information.

Misconception 2: All misdemeanor convictions must be reported.

Not all misdemeanor convictions need to be reported. Traffic citations and certain juvenile adjudications can be excluded from disclosure.

Misconception 3: Only criminal convictions are considered in the application.

The form also addresses administrative proceedings related to professional licenses. Any involvement in such proceedings must be reported.

Misconception 4: A fidelity bond is optional for TPA applicants.

A fidelity bond or comparable insurance is a requirement for all employees, as specified by Ohio law. Proof of this coverage must be submitted with the application.

Misconception 5: The application can be submitted without supporting documents.

Failure to include required attachments, such as proof of insurance and the non-refundable fee, may result in the application being returned or deemed deficient.

Misconception 6: The TPA can commingle funds with personal assets.

The TPA must not mix its personal assets with funds from plan sponsors or participants. This is strictly prohibited by Ohio regulations.

Misconception 7: There is no need to maintain records after the application is submitted.

TPAs must maintain records in accordance with Ohio regulations throughout the administration agreement's term. This includes detailed transaction records and annual reports.

Misconception 8: The application process is simple and quick.

The application process requires careful attention to detail and may take time to complete due to the necessary documentation and compliance requirements.

Misconception 9: Any changes in ownership or management do not need to be reported.

All changes in ownership or management must be reported to the Ohio Department of Insurance as part of the ongoing compliance requirements.

Key takeaways

When filling out and using the Ohio Ins3213 form, keep these key takeaways in mind:

Identify the License Type: Clearly indicate whether you are applying for a resident or non-resident license.
Provide Accurate Demographics: Ensure all business entity information, including name, address, and contact details, is accurate and complete.
Designated Producer: List at least one designated licensed producer responsible for compliance with Ohio's insurance laws.
Background Questions: Answer all background questions truthfully. Attach necessary documentation if you answer "Yes" to any criminal history questions.
Insurance Requirements: Include proof of fidelity bond and professional liability insurance coverage as required by Ohio law.
Record Maintenance: Confirm that your records will be maintained according to state requirements, including transaction records and annual reporting.
Application Attachments: Include all required attachments, such as the non-refundable fee and proof of insurance, to avoid delays.
Sign and Date: Ensure the application is signed and dated by an authorized individual from the business entity.

Following these guidelines will help streamline the application process and improve your chances of a successful submission.