Outline
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 serves as a gateway for businesses to obtain the necessary license from the Illinois Department of Insurance. When filling out the form, applicants must provide key details such as the name of the TPA, tax identification number, and the principal administrative office's address. A fee of $200 is required, payable to the Director of Insurance. Additionally, the form requires information about the business structure, whether it's a corporation, partnership, or proprietorship. Applicants must also disclose the individuals responsible for managing the TPA and any relevant bond requirements. This includes the need for a surety bond, which protects parties involved in the administration of funds and claims. Other important sections address any past regulatory actions or criminal convictions related to the applicant. Completing this form accurately is essential, as any omissions can delay the licensing process. Understanding the Illinois TPA 1 form is the first step toward compliance and successful operation in the insurance landscape of Illinois.
Sample - Illinois Tpa 1 Form
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)
( |
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Corporation |
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State of incorporation ________________________________ |
Year of Incorporation __________ |
( |
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Partnership |
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Year of formation _____________ |
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( |
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Proprietorship |
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Year of formation _____________ |
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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 Information
| Fact Name | Details |
|---|---|
| Governing Law | The Illinois TPA-1 form is governed by the Illinois Revised Statutes related to insurance. |
| Application Fee | A fee of $200 is required, payable to the Director of Insurance. |
| Bond Requirement | Applicants must file a surety bond, with amounts varying based on their operations, ranging from $50,000 to $1,000,000. |
| Exemption Clause | TPAs not maintaining an Administrative Trust Fund (ATF) or Claims Administration Services Account (CASA) may claim exemption from the bond requirement. |
| Application Purpose | This form is specifically for applying for a license to operate as a third-party administrator in Illinois. |
Detailed Guide for Filling Out Illinois Tpa 1
Completing the Illinois TPA 1 form is a straightforward process. It requires accurate information about the third-party administrator and its operations. Make sure to have all necessary documents ready, including any supporting materials mentioned in the instructions. Follow the steps carefully to ensure your application is processed without delays.
- Begin by entering the Name of TPA at the top of the form.
- Provide your Tax or Social Security Number.
- Fill in the Address of your Principal Administrative Office, including the Telephone Number.
- Enter the City, State, and Zip Code.
- Select the Type of business organization by checking the appropriate box: Corporation, Partnership, or Proprietorship. If applicable, include the state of incorporation and year of incorporation or formation.
- If using an assumed name, attach a copy of the DBA registration.
- List the name, title, and address of the person(s) responsible for the TPA. Include multiple entries if necessary.
- Determine the Bond Requirement and indicate the estimated amounts for the Administrative Trust Fund and Claims Administration Services Account, if applicable.
- If claiming a bond exemption, check the appropriate box and provide the name of the administrator.
- Answer questions 11 to 20 regarding previous licenses, convictions, agreements, and affiliations. Attach additional sheets if needed.
- Sign and date the application, confirming your authority to file on behalf of the TPA.
- Attach a check or money order for $200 made out to the Director of Insurance.
Obtain Answers on Illinois Tpa 1
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What is the Illinois TPA-1 form?
The Illinois TPA-1 form is a license application for Third Party Administrators (TPAs) in the state of Illinois. It is required for entities that manage insurance claims and funds on behalf of insurers. The form collects essential information about the TPA, including its name, address, type of business organization, and the individuals responsible for its operations.
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Who needs to fill out the TPA-1 form?
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What is the fee for submitting the TPA-1 form?
The application fee for the TPA-1 form is $200. This fee must be submitted along with the application in the form of a check or money order made payable to the Director of Insurance.
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What information is required on the TPA-1 form?
The form requires various details, including:
- Name and address of the TPA
- Tax or Social Security number
- Type of business organization
- Names and addresses of individuals responsible for the TPA
- Details about any required surety bonds
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What is a surety bond, and is it required?
A surety bond is a financial guarantee that ensures the TPA will fulfill its obligations. Most applicants must file a surety bond as part of their application, unless they qualify for an exemption. The bond amount varies based on the TPA's operations and the funds it manages.
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What happens if the TPA-1 form is incomplete?
If the TPA-1 form is incomplete or missing required information, the application may not be processed. It is crucial to provide all requested details accurately to avoid delays in obtaining the license.
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How long does it take to process the TPA-1 form?
The processing time for the TPA-1 form can vary. Typically, applicants should allow several weeks for the review and approval process. It is advisable to submit the application well in advance of any planned operations as a TPA.
Common mistakes
Filling out the Illinois TPA-1 form can be a straightforward process, but several common mistakes can lead to complications. Understanding these pitfalls can help ensure a smoother application experience.
One frequent error is failing to provide complete and accurate information. Applicants often overlook sections that require specific details, such as the name of the TPA or the tax identification number. Incomplete forms can result in delays or even rejection of the application.
Another mistake involves the submission of incorrect fees. The application requires a payment of $200, but some applicants may send the wrong amount or fail to include a check or money order altogether. This oversight can halt the processing of the application.
Many applicants also neglect to check the box indicating their type of business organization. Whether it is a corporation, partnership, or proprietorship, this information is crucial. Leaving this section unchecked can lead to confusion and further inquiries from the Department of Insurance.
Additionally, not attaching necessary documents is a common issue. For example, if the TPA is registered under an assumed name, a copy of the DBA registration must accompany the application. Failing to include this documentation can result in a request for additional information, prolonging the process.
Some applicants mistakenly believe that they can skip the bond requirement. Unless the administrator is contracted with an insurer and the plan is fully insured, a surety bond is mandatory. Ignoring this requirement can lead to immediate disqualification from receiving a license.
Lastly, applicants often forget to address questions regarding previous regulatory actions or criminal convictions. If any person listed on the application has faced such issues, it is essential to attach the relevant documentation. Omitting this information can lead to significant legal repercussions.
Documents used along the form
When applying for a Third Party Administrator (TPA) license in Illinois, several other forms and documents may be necessary to complete the application process. These documents provide essential information and support for the TPA-1 form.
- Surety Bond Form: This document outlines the bond amount required for the TPA. It serves as a financial guarantee that the administrator will meet its obligations. The bond must be maintained while the TPA is licensed.
- DBA Registration: If the TPA operates under an assumed name, this document must be attached to the application. It proves that the TPA is legally registered to do business under that name.
- Criminal Background Check: A certified copy of any felony convictions or nolo contendere pleas related to the applicant or responsible individuals may be required. This ensures that all parties involved meet the legal standards for operating as a TPA.
- Written Agreements with Insurers: This document details any agreements the TPA has with insurers or plan sponsors. It confirms that the TPA has the necessary contracts in place to operate effectively.
Gathering these documents is crucial for a smooth application process. Ensure that all required forms are completed accurately and submitted on time to avoid delays in obtaining your TPA license.
Similar forms
The Illinois TPA-1 form is a crucial document for third-party administrators seeking licensure in the state. Several other documents share similarities with the TPA-1 form in terms of purpose and required information. Below is a list of five such documents:
- Insurance License Application: Like the TPA-1, this application requires detailed information about the applicant's business structure, ownership, and compliance with state regulations. Both forms aim to ensure that the applicant meets the necessary qualifications to operate within the insurance industry.
- Business Entity Registration Form: This document is similar in that it collects essential information about the business, such as its name, address, and type of organization. Both forms serve to officially recognize the entity and its operations within the state.
- Surety Bond Application: The TPA-1 form includes a bond requirement, which is also a key component of a surety bond application. Both documents address the financial responsibility of the applicant and provide assurances to protect parties involved in the administration of funds.
- Certificate of Good Standing: This document verifies that a business is compliant with state regulations, similar to the TPA-1 form's requirement for disclosures about the applicant's legal standing. Both documents ensure that the entity is authorized to conduct business and has not faced significant legal issues.
- Provider Credentialing Application: This application is used by healthcare providers to demonstrate their qualifications and compliance with state regulations. Like the TPA-1, it requires detailed personal and professional information to ensure that the applicant meets industry standards.
Dos and Don'ts
When filling out the Illinois TPA 1 form, there are important guidelines to follow. Adhering to these can help ensure that your application is processed smoothly.
- Do: Print or type all information clearly, except where a signature is required.
- Do: Attach a check or money order for $200 made out to the Director of Insurance.
- Do: Provide accurate and complete information for all required fields, including the names and addresses of responsible individuals.
- Do: Attach any necessary documents, such as DBA registration or copies of relevant legal orders, if applicable.
- Don't: Leave any sections blank; all required fields must be filled out.
- Don't: Forget to check the box for bond exemption if applicable, and provide the required details.
- Don't: Submit the form without ensuring that all attachments are included and properly formatted.
- Don't: Delay in notifying the Director of Insurance about any significant changes in information after submission.
Misconceptions
Misconceptions about the Illinois TPA 1 form can lead to confusion for applicants. Here are six common misunderstandings:
- A TPA license is always required. Many believe that a license is necessary for all types of third-party administrators. However, a TPA license is not required to administer fire and casualty funds or claims.
- The application fee is negotiable. Some applicants think they can negotiate the $200 fee. This fee is set by the Illinois Department of Insurance and is non-negotiable.
- All applicants need to maintain a surety bond. There is a misconception that every applicant must file a surety bond. In fact, if the applicant does not maintain an Administrative Trust Fund (ATF) or a Claims Administration Services Account (CASA), they can claim an exemption from the bond requirement.
- Past regulatory actions automatically disqualify applicants. Some applicants fear that any past denial, suspension, or revocation of a license will prevent them from obtaining a new license. While this information must be disclosed, it does not automatically disqualify them.
- Felony convictions always result in disqualification. There is a belief that any felony conviction will disqualify an applicant. While such convictions must be reported, each case is evaluated individually based on its circumstances.
- All business records must be kept in the U.S. Some assume that all records related to the business must be located within the United States. However, applicants can have records created or located outside the U.S. as long as they meet other requirements.
Key takeaways
Here are some key takeaways for filling out and using the Illinois TPA 1 form:
- Complete the form accurately: Make sure to print or type all required information clearly, except where a signature is needed.
- Include the fee: Attach a check or money order for $200, made out to the Director of Insurance.
- Understand licensing requirements: A TPA license is not necessary for administering fire and casualty funds or claims.
- Provide complete information: Fill in the TPA name, address, and details about the business organization, including the type of entity.
- Bond requirements: Be aware that a surety bond may be required unless you meet specific conditions related to insurance contracts.
- Disclose any issues: Answer questions regarding past regulatory actions or felony convictions truthfully, as this information is crucial for your application.
- Notify of changes: If your application is approved, you must inform the Director of Insurance about any significant changes within 30 days.