CHAPTER
Ins 2300 THIRD
PARTY ADMINISTRATORS
Statutory
Authority: RSA 400-A:15, I; RSA 402-H:15
PART
Ins 2301 REGULATION
OF THIRD PARTY ADMINISTRATORS
Ins 2301.01 Purpose. The purpose of this part is to provide for
the regulation and licensing of third party
administrators and to set forth rules and procedural requirements which the
commissioner deems necessary to carry out the provisions of RSA 402-H.
Source. #5787, eff 2-14-94; ss by #7023, eff 7-1-99;
ss by #7318, eff 8-1-00, EXPIRED: 8-1-08
New. #9510, eff 7-10-09; ss by #12228, eff 7-10-17
Ins 2301.02 Definitions.
(a) “Administrator" means “third
party administrator (TPA)" as defined in RSA 402-H:1, I.
(b)
"Affiliate" means “affiliate” as defined in RSA 402-H:1,
II. The term includes “affiliated”.
(c)
"Commissioner" means the commissioner of insurance.
(d)
"Control" means "control" as defined in RSA 401-B:1,
III.
(e)
"Employee Retirement Security Act of 1974" means
"ERISA", Pub.L. 93-406, 88 Stat. 829,
effective September 2, 1974.
(f)
"Insurer" means "insurer" as defined in RSA 402-H:1,
VII.
(g)
"Person" means an individual or business entity.
(h) "Underwrites" means
“underwrites” as defined in RSA 402-H:1, XIII.
The term includes underwriting.
Source. #5787, eff 2-14-94; ss by #7023, eff 7-1-99;
ss by #7318, eff 8-1-00, EXPIRED: 8-1-08
New. #9510, eff 7-10-09; ss by #12228, eff 7-10-17
Ins 2301.03 Application Forms.
(a)
An administrator shall not operate as an administrator in this state
without a certificate of authority or exemption from the department. Administrators wishing to do business in this
state shall complete an application, an exemption registration, which shall be
filed annually on a form provided by the department pursuant to requirements in
RSA 402-H:11 and attached hereto as Appendix 1, Form TPA-1.
Persons or entities that are specifically excepted by RSA
402-H:1, I shall complete an exception from licensing form, which shall be
filed annually on a form provided by the department pursuant to the
requirements of RSA 402-H:1, I(a) through (m) and attached hereto as Appendix
2, Form TPA-2.
(b)
The application shall be completed and signed by an officer or
authorized representative of the administrator.
The complete application shall be filed at the department. The application shall be accompanied by the
filing fee required in RSA 400-A:29, I(a).
(c)
For any pooled risk management program operated pursuant to RSA 5-B, a
completed copy of the RSA 5-B:4 informational filing may be submitted as an
exemption registration.
(d)
An application or exemption registration shall not be deemed to be filed
until all of the information necessary to properly
process the application or exemption has been received by the
commissioner.
(e)
An application by a corporation, association, partnership
or benefit society shall be accompanied by a current certificate of good
standing as a business corporation in this state.
(f)
An administrator shall notify the commissioner in writing of any change
in the information required to be filed under these rules including, but not limited
to, a change of address or name, no later than 30 days after the change.
(g)
Where any form used for compliance with this rule mentions perjury,
perjury shall mean any applicable penalty found in RSA 641, falsification in
official matters, including RSA 641:3, unsworn falsification.
Source. #5787, eff 2-14-94;
ss by #7023, eff 7-1-99; ss by #7318, eff 8-1-00; amd
by #7506, eff 6-25-01; paras. (a)-(c)(14), (c)(16)a. -
(24), (d)(1)-(9), & (f)-(h) EXPIRED:
8-1-08; paras. (c)(15), (16) intro., (25), (d)(10), & (e) EXPIRED: 6-25-09
New. #9510, eff 7-10-09; ss by #12228, eff
7-10-17; ss by #13070, eff 7-22-20
Ins 2301.04 Disclosure of Information.
(a)
Each applicant for a certificate of authority as an administrator shall
indicate on the application whether the applicant has:
(1) Ever been denied a license or certificate of
authority as an insurance agent, broker, or administrator;
(2) Been licensed or authorized as an insurance
agent, broker, or administrator;
(3) Had a license or certificate of authority as
an insurance agent, broker, or administrator suspended or revoked or has been
denied the renewal of such license; and
(4) Had any contract as an agent or administrator
for an insurer cancelled for cause and, if so, the facts concerning that
action.
Source. #5787, eff 2-14-94; ss by #7023, eff 7-1-99;
ss by #7318, eff 8-1-00, EXPIRED: 8-1-08
New. #9510, eff 7-10-09; ss by #12228, eff 7-10-17
Ins 2301.05 Surety Bond.
(a)
An administrator that administers benefit plans for an insurer that is
not licensed in New Hampshire, a multiple employer welfare arrangement, or a
church plan shall include a surety bond in a minimum amount of $100,000 or 10
percent of the administrator's average daily client account balance during the
preceding calendar year, but not more than $1,000,000.
(b)
If an administrator cannot obtain a bond, then another security,
including, but not limited to, cash or negotiable securities in an amount equal
to the amount of the required surety bond shall be set aside in one or more
trusteed bank accounts in the State of New Hampshire under trust terms that
require the commissioner’s signature for any account activity, except the
accumulation of interest or other funds into the account, and allow the
commissioner, by order, to disburse the trust funds for the satisfaction of
policyholder or customer claims.
(c)
To be acceptable the surety bond shall be:
(1) Unconditional;
(2) Be issued by a bank or insurer licensed to do
business in New Hampshire; and
(3) Be payable to the commissioner to ensure the
financial protection of the administrator’s customers, subject to the dollar
limitation of the surety bond.
Source. #5787, eff 2-14-94;
ss by #7023, eff 7-1-99; ss by #7318, eff 8-1-00; amd by #7506, eff 6-25-01;
EXPIRED: 8-1-08 except for para. (c)(3)
New. #9510, eff 7-10-09; ss by #12228, eff 7-10-17
Ins 2301.06 Audited Financial Statement.
(a)
Each renewal of a certificate of authority shall be accompanied by the
applicant's current audited financial statement.
(b)
The financial statement shall reflect a positive net worth in order to be acceptable as proof of the applicant's
financial responsibility.
(c)
The department, in determining an applicant's ability to pay his
obligations when due, shall request reports of the applicant's credit and
present financial condition.
Source. #5787, eff 2-14-94; ss by #7023, eff 7-1-99;
ss by #7318, eff 8-1-00, EXPIRED: 8-1-08
New. #9510, eff 7-10-09; ss by #12228, eff 7-10-17
Ins 2301.07 Written Agreement Necessary.
(a)
An administrator shall not act on behalf of an insurer without a written
agreement with an insurer or other person for whom the services are performed.
(b)
Pursuant to RSA 402-H:2, the agreement shall be retained by the
administrator and the insurer for the period of the contract and for 5 years
beyond the contract's termination.
(c)
The agreement shall contain:
(1) The names and addresses of the parties to the
contract;
(2) An enumeration of the responsibilities and
contractual obligations of the parties to the agreement;
(3) Provisions for contract termination by either
of the parties to the agreement and provisions for the fulfillment of any
lawful obligations with respect to policies affected by the written agreement;
(4) The lines, classes, or types of insurance to
be administered;
(5) The underwriting or other standards to be
used and administered;
(6) The financial arrangement for the transfer of
funds between the insurer and the administrator in the conduct of business as
stipulated in the contract; and
(7) Other special provisions deemed necessary by
the parties to the contract.
Source. #5787, eff 2-14-94; ss by #7023, eff 7-1-99;
ss by #7318, eff 8-1-00, EXPIRED: 8-1-08
New. #9510, eff 7-10-09; ss by #12228, eff 7-10-17
Ins 2301.08 Fiduciary Obligation.
(a)
Any money received by a TPA as premium or return premium on or under any
policy of insurance or application therefor shall be received by the TPA in its
fiduciary capacity.
(b)
Any TPA who appropriates to its own use, or with intent to appropriate
to its own use, takes, secretes, withholds, lends, invests, or otherwise
disposes of, or uses or applies any such premium or return premium received by
it, contrary to the instructions or without the consent of the insurer for or
on account of which the same was received by it, shall be deemed to have
violated this part, irrespective of whether the TPA has or claims to have any
commission or other interest in such premium or return premium.
(c)
A TPA shall hold premiums and return premiums as a trustee, and not as
the owner of the beneficial title to the funds.
A TPA shall treat all premiums and return premiums as trust funds and
segregate them from the TPA’s own funds.
(d)
The TPA shall keep an accurate record of all fiduciary funds in
accordance with Ins 2301.13. The TPA shall not treat insurance premiums or
return premiums as personal assets. The
TPA's financial statement shall clearly show those funds which are held in
trust accounts for the benefit of insurers and the liability section of the
TPA's statement shall reflect the balances due companies from such trust
accounts. A TPA shall not use fiduciary
funds as collateral for a personal or business loan.
(e) In order to meet its fiduciary obligations, a
TPA shall set up a trust account in a bank or financial institution and
maintain all fiduciary funds in such bank or financial institution until actually remitted to the insurer or person entitled
thereto. The remittance of premiums
shall be governed by the terms of the individual contracts or agreements
between the TPA and insurer.
Source. #5787, eff 2-14-94; ss by #7023, eff 7-1-99;
ss by #7318, eff 8-1-00, EXPIRED: 8-1-08
New. #9510, eff 7-10-09; ss by #12228, eff 7-10-17
Ins 2301.09 Establishment of Premium
Trust Account.
(a)
Each TPA that collects premium or return premiums shall establish a
premium trust account for New Hampshire business.
(b)
If the account is interest bearing, the requirements of Ins 2301.11 shall be observed.
(c)
Fiduciary funds on New Hampshire business shall at all
times be maintained in the premium trust account separate from any other
account or depository. Such account
shall be in an amount at least equal to the premiums and return premiums, net
of commission, received by the TPA and unpaid to the persons entitled thereto
or, at such persons' direction or pursuant to written contract, for the account
of such persons.
(d)
The TPA's New Hampshire premium trust account signature card shall
contain the following notation: "This is an insurance premium trust
account maintained under the provisions of Chapter Ins 2300, Part Ins 2301."
(e)
Checks drawn on the premium trust account shall bear the notation
"Premium Trust Account."
Source. #5787, eff 2-14-94; ss by #7023, eff 7-1-99;
ss by #7318, eff 8-1-00, EXPIRED: 8-1-08
New. #9510, eff 7-10-09; ss by #12228, eff 7-10-17
Ins 2301.10 Commingling of Funds
Prohibited.
(a)
Under no circumstances shall a TPA place fiduciary funds in a personal
or business operating account. The TPA may
retain commission income or other funds in its premium trust account in order to advance premiums, establish reserves for paying
return commissions or for such contingencies as might arise in the business of
receiving and transmitting premiums or return premium funds.
(b)
The TPA may retain a portion of his or her unearned commissions in the
premium trust account in order to avoid being short in
the event of a policy cancellation. When
a policy is cancelled and the return premium is received by the TPA by means of
a credit or otherwise, those funds shall be placed in the premium trust account
until remitted to the insured entitled thereto.
(c)
Cash premium payments shall not be deposited into the TPA's personal
account in order to draw a personal check in the
amount of net premium payment to the insurer.
The use of personal checks to transmit fiduciary funds shall be
prohibited in any situation that results in commingling the fiduciary funds
with the TPA's personal funds.
Source. #5787, eff 2-14-94; ss by #7023, eff 7-1-99;
ss by #7318, eff 8-1-00, EXPIRED: 8-1-08
New. #9510, eff 7-10-09; ss by #12228, eff 7-10-17
Ins 2301.11 Interest-Bearing Accounts. A TPA shall only utilize interest-bearing
accounts that require no advance notice for the withdrawal of funds, and the
TPA shall arrange all such interest-bearing accounts so that funds therein
contained shall be immediately available during normal business hours.
Source. #5787, eff 2-14-94; ss by #7023, eff 7-1-99;
ss by #7318, eff 8-1-00, EXPIRED: 8-1-08
New. #9510, eff 7-10-09; ss by #12228, eff 7-10-17
Ins 2301.12 Return Premiums. The TPA shall retain the return premium in
the trust account until remittance to the client is made. Remittance to the client shall occur no later
than 45 days from the date the return premium is determined. If the return premium cannot be delivered to
the insured entitled thereto, the funds shall be returned to the insurer. The insurer shall report the funds escheated
to the state of New Hampshire, in accordance with applicable statutes.
Source. #5787, eff 2-14-94; ss by #7023, eff 7-1-99;
ss by #7318, eff 8-1-00, EXPIRED: 8-1-08
New. #9510, eff 7-10-09; ss by #12228, eff 7-10-17
Ins 2301.13 Recordkeeping Requirements.
(a)
The following records relative to the premium trust account shall be maintained at all times by the TPA:
(1) Periodic statements of account supplied by
the bank for all premium trust accounts maintained pursuant to this part;
(2) Records of all deposits made into each
premium trust account;
(3) Cancelled checks drawn on, or records of
withdrawal of funds from, such premium trust accounts; and
(4) An accounts receivable listing or similar
record.
(b)
All records described above shall be kept in the principal office of the
TPA.
(c)
All records shall be maintained in an orderly manner so that the
information therein is readily available and shall be open to
inspection or examination by the commissioner at all times. The commissioner shall require a TPA to
furnish the department any information maintained or required to be maintained.
Source. #5787, eff 2-14-94; ss by #7023, eff 7-1-99;
ss by #7318, eff 8-1-00, EXPIRED: 8-1-08
New. #9510, eff 7-10-09; ss by #12228, eff 7-10-17
Ins 2301.14 Periodic Audit.
(a)
The commissioner shall examine an administrator pursuant to RSA 402-H:4,
II on a regularly scheduled basis or pursuant to RSA 402-H:13 when an
evaluation of any submission to the department by the administrator, insurer, policyholder or publication indicates potential financial or
operational irregularities contrary to statute or rule. The cost of the audit shall be paid by the
administrator pursuant to RSA 402-H:13.
Audits shall include, but not be limited to financial condition, premium
collection, claims processing and marketing practices.
(b)
Any one or more of the following factors present shall require an
additional amount of security:
(1) A material reduction in liquid assets or
retained earnings, or liquid assets below the level that would be called for in
a surety bond;
(2) A deteriorating financial condition, as
evidenced through an audit by the commissioner or any other insurance commissioner;
and
(3) Any other relevant considerations
jeopardizing insurers and insureds, including a pattern of complaints by
consumers, material litigation, revocation or cancellation of surety bonds or
errors and omissions insurance coverage, missing, incomplete, or inaccurate
financial and transaction records.
(c)
The administrator shall have continuing access to all books and records in order to fulfill its contractual obligations.
(d)
All books and records maintained by the administrator as part of that
contractual obligation shall:
(1) Be owned by the insurer or the administrator;
(2) Conform to the standards of insurance record
keeping required of insurers subject to filing an annual audited financial
statement pursuant to RSA 400-A:36;
(3) Be retained for 5 years from the date of
their creation; and
(4) Be subject to examination by the commissioner
or the insurer for which the records are kept.
(e)
Upon termination of an agreement between the administrator and person
contracting for the services pursuant to the termination provisions in the
agreement, the records may be transferred to a new administrator in lieu of the
required 5 year retention. If such a transfer occurs, the new
administrator shall acknowledge in writing that he/she has received the records
and shall be responsible for them.
Source. #5787, eff 2-14-94; ss by #7023, eff 7-1-99;
ss by #7318, eff 8-1-00, EXPIRED: 8-1-08
New. #9510, eff 7-10-09; ss by #12228, eff 7-10-17
Ins 2301.15 Responsibilities of the
Insurer.
(a)
The insurer shall be responsible for determining benefits, premium
rates, underwriting criteria, and claims payment procedures applicable to the
coverage and for securing reinsurance.
(b)
The standards pertaining to (a) above shall be provided in writing by
the insurer to the administrator.
(c)
If the administrator has any responsibility for the development or
formulation of the items in (a) above, they shall be set forth in the written
agreement between the administrator and the person contracting for the
services.
(d)
The insurer shall conduct semiannual reviews of the operations of the
administrator if the administrator administers benefits for more than 100
certificate holders on behalf of the insurer.
One such review shall consist of an on-site audit by the insurer.
Source. #5787, eff 2-14-94; ss by #7023, eff 7-1-99;
ss by #7318, eff 8-1-00, EXPIRED: 8-1-08
New. #9510, eff 7-10-09; ss by #12228, eff 7-10-17
Ins 2301.16 Approval of Advertising.
(a) All advertising conducted by the
TPA on behalf of the insurer shall be approved in writing by the insurer in
advance of its use.
(b)
Advertisements of insurance shall comply with the provisions of Ins 2600.
Source. #5787, eff 2-14-94; ss by #7023, eff 7-1-99;
ss by #7318, eff 8-1-00, EXPIRED: 8-1-08
New. #9510, eff 7-10-09; ss by #12228, eff 7-10-17
Ins 2301.17 Grounds for Denial,
Non-renewal, Suspension, or Revocation of Certificate; Penalty.
(a)
An administrator shall be subject to the provisions of RSA 402-H:14 and
RSA 402-H:16 for the following reasons:
(1) Failure to comply with any provisions of
these rules or of RSA 402-H;
(2) Failure to comply with any lawful order of
the commissioner;
(3) Committing an unfair or deceptive act or
practice as described in RSA 417;
(4) Deterioration of financial condition
adversely affecting the certificate holder's ability to operate as an administrator;
(5) Filing an application or any necessary forms
with the department which contain fraudulent information or omissions;
(6) Misappropriation, conversion, illegal
withholding, or refusal to pay over, upon proper demand, any monies that belong
to a person otherwise entitled to them and that have been entrusted to the
administrator in his/her fiduciary capacity;
(7) Evidence that an owner, principal, officer,
partner, manager, director, stockholder, trustee, employee of the
administrator, or the administrator itself has:
a. Had an insurance license or an application
for an insurance license in any state denied, suspended, or revoked;
b. Been the subject of a fine, penalty, order,
withdrawal, or informal settlement with any state insurance department; or
c. Pled guilty or no contest to any felony or
misdemeanor; or
(8) At any time fails to meet any qualification
for which the issuance of the certificate could have been refused had such
failure then existed and been known to the Department.
Source. #5787, eff 2-14-94; ss by #7023, eff 7-1-99;
ss by #7318, eff 8-1-00; ss by #7506, eff 6-25-01, EXPIRED: 6-25-09
New. #9510, eff 7-10-09; ss by #12228, eff 7-10-17
Ins 2301.18 Inquiry by Commissioner.
(a)
The commissioner shall address any inquiries to the administrator
concerning its TPA business. The
administrator shall reply in writing to any inquiry made by the commissioner
pursuant to Ins 1001.01(c).
(b)
An administrator shall keep all complaints on file for a period of 5
years. Complaint information shall be made
available to the department by the administrator upon the commissioner's
request.
Source. #5787, eff 2-14-94; ss by #7023, eff 7-1-99;
ss by #7318, eff 8-1-00, EXPIRED: 8-1-08
New. #9510, eff 7-10-09; ss by #12228, eff 7-10-17
Ins 2301.19 Hearing and Appeal. Prior to denying an application or a renewal
application or suspending or revoking a certificate issued under this part, a
certificate holder shall be provided with written notice of the commissioner's
allegations and provided an opportunity for a hearing as provided in RSA 400-A
and Ins 200.
Source. #5787, eff 2-14-94; ss by #7023, eff 7-1-99;
ss by #7318, eff 8-1-00, EXPIRED: 8-1-08
New. #9510, eff 7-10-09; ss by #12228, eff 7-10-17
Ins 2301.20 Violations and Penalties.
(a) Non-compliance with Ins
2301.03 through Ins 2301.16 shall be a violation under RSA 402-H. The department shall specify which sections,
including specific subsections if any, of RSA 402-H are allegedly violated in
any enforcement action brought under this section.
(b)
In addition to any other penalties provided by the laws of this state for violating a rule, an administrator
or individual who violates a requirement of the administrative rules sections
cited in (a) above shall, after notice and hearing in accordance with the
procedures set forth in Ins 200, be subject to
suspension, revocation, or administrative penalty pursuant to RSA 402-H:16.
Source. #5787, eff 2-14-94;
ss by #7023, eff 7-1-99; ss by #7318, eff 8-1-00; amd by #7506, eff 6-25-01
(paras. (c) & (d) deleted); EXPIRED: 8-1-08
New. #9510, eff 7-10-09; ss by #12228, eff 7-10-17
Ins 2301.21 Waiver or Suspension of
Rules.
(a)
The commissioner, upon the commissioner’s own initiative or upon request
by an insurer, shall waive any requirement of this chapter if such waiver does
not contradict the objective or intent of the rule and:
(1) Applying the rule provision would cause confusion
or would be misleading to consumers;
(2) The rule provision is in whole or in part
inapplicable to the given circumstances;
(3) There are specific circumstances unique to
the situation such that strict compliance
with
the rule would be onerous without promoting the objective or intent of the rule
provision; or
(4) Any other similar extenuating circumstances
exist such that application of an alternative standard or procedure better
promotes the objective or intent of the rule provision.
(b)
No requirement prescribed by statute shall be waived unless expressly
authorized by law.
(c)
Any person or entity seeking a waiver shall make a request in writing.
(d)
A request for a waiver shall specify the basis for the waiver and
proposed alternative, if any.
Source. #12228, eff 7-10-17
APPENDIX 1
Form TPA-1 Application Certification
I. APPLICATION
CERTIFICATION
THIRD
PARTY ADMINISTRATOR
R.S.A.
402-H
ADMINISTRATOR
NAME:
TRADE
NAME (if any):
DOMICILE:
ADDRESS:
CONTACT
NAME:
CONTACT
TITLE: PHONE:
CONTACT
ADDRESS:
Note: The Department shall address all correspondence
regarding this application to the named contact person. The named contact person may be an employee
of the company or a contracted individual.
FEES
Application
Examination (RSA 400-A:29 I.(a)) $1,000.00
Annual
Report Filing Fee (RSA 400-A:29 III.) $100.00
(Due
March 1st of each year following licensure)
Annual
Renewal (RSA 400:29 I.(c)) $100.00
(Due
June 14th each year following licensure)
All
checks shall be made payable to: New Hampshire Insurance Department
All
application, annual reporting, and annual renewal fees shall be filed with the
respective
documents.
SECTION
1 MANAGEMENT
1.) OFFICIAL LIST OF ALL INDIVIDUALS responsible
for the conduct of affairs of the administrator. The list shall give the name,
position occupied, address and the professional qualifications of each of these
individuals. It shall also be sworn to as a true and complete list by the
secretary of the administrator. The list shall include:
·Board of
Directors
·Board of
Trustees
·Executive
Committee/Governing Board/Committee
·Principal
Officers
·Shareholders
(10% or more) Others exercising control/influence
·Any other
individual who exercises control or influence over the affairs of the
administrator
SECTION
2 FINANCIAL
1.) STATUTORY DEPOSIT as indicated below. Please
note that no bonding shall be required by the commissioner of any administrator
whose business is restricted solely to benefit plans which are either fully
insured by an authorized insurer or which are bona fide employee benefit plans
established by an employer or any employee organization, or both, for which the
insurance laws of this state are preempted pursuant to the Employee Retirement
Income Security Act of 1974.
· A safekeeping or trust receipt from a New
Hampshire bank indicating that a minimum of
$100,000.00
has been placed with that bank and pledged to the commissioner of insurance of
the State of New Hampshire, or
· A surety bond issued for a minimum of
$100,000.00 by a surety company licensed to do business in the State of New
Hampshire.
2.) THE PHYSICAL ADDRESS WHERE THE BOOKS AND
RECORDS MAINTAINED BY THE ADMINISTRATOR ARE LOCATED:
3.) THE FOLLOWING DOCUMENTS SHALL BE INCLUDED
WITH THE APPLICATION:
·Federal
Tax Returns (last 3 years)
·Audited
Financial Statement (2 most recent years)
SECTION
3 DOCUMENTARY
1.) CERTIFIED COPIES OF ALL BASIC ORGANIZATIONAL
DOCUMENTS, including Articles of Incorporation, Articles of Association,
partnership agreements, trade name certificate, trust agreement, shareholder
agreement, recent certificate of good standing for state of domicile and for
the State of New Hampshire, and all amendments thereto. These items shall be
certified by the proper domiciliary state official.
2.) COPY OF THE BY-LAWS of the applicant
certified as a true and correct copy of the secretary of the company.
3.) BUSINESS PLAN STATEMENT. Attach a separate
sheet outlining the Administrator's Business Plan, including staffing levels
proposed for New Hampshire and nationwide.
4.) SUMMARY of INSURANCE POLICIES. Attach copies
of binder pages from insurance carriers for Administrator's:
"Errors
& Omissions" Insurance (carrier/limits/policy period)
"Directors
& Officers" Insurance (carrier/limits/policy period)
Any
other pertinent coverages (carrier/limits/policy period)
5.) If the applicant shall be managing the solicitation
of new or renewal business or shall be directly soliciting insurance contracts
or otherwise acting as an agent, furnish the name and New Hampshire agent
license number(s) of the individual (s) who shall be performing these duties
and indicate if they are contract workers or employees. Please be aware that
these individuals shall need a current appointment with the insurer (s) for
which they shall be soliciting.
Name License
# Employment Status
6.) If the applicant is currently contracted with
any insurer as a third party administrator include a
copy of each contract and a "Notice of Contract" shall be completed
for each contract and submitted to this Office. (form attached, reproduce as
needed)
7.) The license or authority of the administrator
in any state, district or country has at no time been revoked, suspended
or cancelled, nor has it been refused admission to any state, district or
country, except as stated below. (state in full detail any exception)
NOTARIZATION
STATE
of
COUNTY
of
BEFORE
ME, the undersigned authority, personally appeared
__________________________________ who, being duly sworn, stated that all information
contained in the attached application for licensure is, to the best of his
knowledge, true, complete and correct.
(Witness Signature) (Authorized
Representative - Signature)
(Printed Name) (Printed Name)
Sworn
to and subscribed before me this ________ day of
in
the year _________
Notary
Public Signature
(Printed
Name)
II. BIOGRAPHICAL AFFIDAVIT
BIOGRAPHICAL
AFFIDAVIT
(Print
or Type)
Full
Name and Address of Company (Do Not Use Group Names)
In
connection with the above-named company, I herewith make representations and supply
information about myself as hereinafter set forth. (Attach addendum or separate
sheet if space hereon is insufficient to answer any question fully.) IF ANSWER
IS "NO" OR "NONE", SO STATE.
1.
Affiant's Full Name (Initials Not Acceptable):
2. a. Have you ever had your name changed?
b. Other names used at any time.
3. Affiant's Social Security Number.
4. Date
and Place of Birth.
5. Affiant's Business Address.
Business
Telephone.
6. List your residences for the last ten (10)
years starting with your current address, giving:
Date Address City and State
7.
Education: Dates, Names,
Locations and Degrees.
College:
Graduate
Studies:
Other:
8.
List memberships in Professional Societies and Associations.
9.
Present or Proposed Position with the Applicant Company.
10.
List complete employment record (up to and including present jobs,
positions, directorates or officerships) for the past
twenty (20) years, giving:
DATES EMPLOYER
AND ADDRESS TITLE
11.
Present employer may be contacted. YES NO
Former
employer may be contacted. YES NO
12. a. Have
you ever been in a position which required a fidelity bond? If any claims were
made on the bond, give details.
b. Have you ever been denied an individual or
position schedule fidelity bond, or have a bond cancelled or revoked? If yes, give details.
13. List any professional, occupational, and
vocational licenses issued by any public or governmental licensing agency or
regulatory authority which you presently hold or have held in the past (state
date license issued, issuer of license, date terminated, reasons for
termination).
14. During the last ten (10) years, have you ever
been refused a professional, occupational, or vocational license by any public
or governmental licensing agency or regulatory authority, or has any such
license held by you ever been suspended or revoked? If yes, give details.
15. List any insurers in which you control
directly or indirectly or own legally or
beneficially 10% or more of the outstanding stock (in voting power). If
any of the stock is pledged or hypothecated in any way give details.
16. Will you or members of your immediate family
subscribe to or own, beneficially or of record, shares of stock of the
applicant insurance company or its affiliates? If any of the shares or stock
are pledged or hypothecated in any way, give details.
17. Have you ever been adjudged a bankrupt?
18. a.
Have you ever been convicted or had a sentence imposed or suspended or
had pronouncement of a sentence suspended or been pardoned for conviction of or
pleaded guilty or nolo contendere to any information or indictment charging any
felony, or charging a misdemeanor involving embezzlement, theft, larceny, or
mail fraud, or charging violation of any corporate securities statute or any
insurance law, or have you been subject of any disciplinary proceedings of any
federal or state regulatory agency?
If
yes, give details.
b. Has any company been so charged, allegedly as a result of any action or conduct on your part? ______ If
yes, give details.
19. Have you ever been an officer, director,
trustee, investment committee member, key employee, or controlling stockholder
of any insurer which, while you occupied any such position or capacity with
respect to it, became insolvent or was placed under supervision or in
receivership, rehabilitation, liquidation or
conservatorship?
20. Has the certificate of authority or license
to do business of any insurance company of which you were an officer or director or key management person ever been suspended or
revoked while you occupied such position?
If
yes, give details.
Dated
and signed this day of at
_____________________________________
I hereby certify under penalty of perjury that I am acting on behalf, and that
the foregoing statements are true and correct to the best of my knowledge and
belief.
(Signature
of Affiant)
State
of
County
of
Personally appeared before
me the above named ___________________________________________________
personally known to me, who, being duly sworn, deposes and says that he
executed the above instrument and that the statements and answers contained
therein are true and correct to the best of my knowledge and belief.
Subscribed
and sworn to before me this day
of 20
(Notary
Public)
My
Commission Expires
SEAL
III. NOTICE of CONTRACT
BETWEEN
THIRD PARTY ADMINISTRATOR
AND
INSURER OR OTHER PERSON
ADMINISTRATOR
NAME:
TRADE
NAME (if used):
ADDRESS:
NAME
of INSURER:
ADDRESS:
CONTACT
NAME:
CONTACT
TITLE: PHONE:
CONTACT
ADDRESS:
Under
the terms of the attached contract, the administrator shall be responsible for:
(check those which apply)
______ Solicitation
of Coverage ______ Underwriting
______ Collection
Charges/Premium ______ Claims Adjustment
______ General
Management Services ______ Distribution Ad Materials
______ Claims
Payment ______ Other (explain)
Effective
Date of Contract:
Physical
location of books and records maintained by the administrator in regard to this agreement:
Also
include the following items:
A copy of the contract between the administrator and
insurer or other person.
A copy of the notification which shall be sent to
policyholders informing them of this arrangement.
Copies of all advertisement and marketing materials to
be distributed by the administrator.
Level of reinsurance provided for the benefit of
insureds under this contract, include carrier name.
Actual or estimated annual losses paid for a 3 year period.
(Signature
of Administrator Representative) (Signature of Insurer Representative)
(Printed
Name) (Printed Name)
IV, REQUEST for an
EXEMPTION of LICENSURE
as
a THIRD PARTY ADMINISTRATOR
in
New Hampshire
An
administrator is not required to hold a license as an administrator in this
state under certain conditions set forth in RSA 402-H:11-b. An exemption shall
be requested by completing this form and page one of the licensing application
and submitting it to this Department. No fee is charged for the registration of
an exempted administrator. The Department shall notify the applicant if the
request for an exemption is approved. This exemption shall be renewed no later
than June 14th of every year subsequent to the initial
application.
ADMINISTRATOR
NAME:
The
above named administrator hereby requests an exemption from licensure because
we meet the following requirement (s): (check those which apply)
_____ An association administering
a pooled risk management program operated pursuant to RSA 5-B.
_____ A association
conducting business that is exempt from taxation under the Internal Revenue
Code, Section 115.
NOTARIZATION
STATE
of
COUNTY
of
BEFORE
ME, the undersigned authority, personally appeared
_____________________________________ who being duly sworn, stated that all
information contained in the attached application for exemption of licensure
is, to the best of his knowledge, true, complete and
correct.
(Witness
Signature) (Authorized
Representative Signature)
(Printed
Name) (Printed
Name)
Sworn
to and subscribed before me this __________ day of _______in the year
____________
(Notary
Public Signature)
(Notary
Public Printed Name)
APPENDIX
2
Form TPA-2 Authorization of Exception
I. REQUEST for an EXCEPTION from LICENSURE
as a THIRD PARTY
ADMINISTRATOR
in New Hampshire
Certain
persons or entities are not required to hold a license as an administrator in
this state under certain conditions set forth in RSA 402-H:1, I (a) through
(m). An exception shall be requested by completing this form and page one of
the licensing application and submitting it to this Department. No fee is
charged for the registration of an excepted person or entity. The Department
shall notify the applicant if the request for an exception is approved. This
exception shall be renewed no later than June 14th of every year subsequent to the initial application.
EXCEPTED
PERSON OR ENTITY NAME:
The
above named excepted person or entity hereby requests an exception from
licensure because we meet the following requirement (s): (check those which apply)
_____ An employer, or a wholly
owned direct or indirect subsidiary of an employer, on behalf of
its
employees or the employees of one or more subsidiaries or affiliated
corporations of such
employer.
_____ A union on behalf
of its members.
_____ An insurer which is authorized to
transact insurance in this state pursuant to RSA 401, or a
subsidiary or affiliated corporation
of such insurer, with respect to a policy lawfully issued and
delivered in and pursuant to the laws
of this state.
_____ An insurance producer licensed to sell
life or health insurance or annuities or workers'
compensation insurance in this state,
acting on behalf of an authorized insurer.
_____ A creditor on behalf of its debtors
with respect to insurance covering a debt between the
creditor and its debtors.
_____ A trust and its trustees, agents and
employees acting pursuant to such trust established in
conformity with 29 U.S.C. section 186.
_____ A trust exempt from taxation under
Section 501(a) of the Internal Revenue Code, its
trustees
and employees acting pursuant to such
trust, or custodian and the
custodian's agents or
employees acting pursuant to a
custodian account which meets the requirements of Section 401(f)
of the Internal Revenue Code.
_____ A credit union or a financial
institution which is subject to supervision or examination by
federal or state banking authorities,
or a mortgage lender, to the extent it collects and remits
premiums to licensed insurance
producers or authorized insurers in connection with loan payments.
_____ A credit card issuing company which
advances for and collects insurance premiums or
charges from its credit card holders
who have authorized collection.
_____ A person who adjusts or settles claims
in the normal course of that person's practice or
employment as an attorney at law and
who does not collect charges or premiums in connection
with life, annuity, or health coverage
or workers' compensation insurance.
_____ An adjuster
licensed by this state whose activities are limited to adjustment of claims.
_____ A person subject to regulation under
RSA 281-A:5-d or under a self-funded governmental
plan that is exempt from the
provisions of the Employee Retirement Income Security Act (ERISA)
pursuant to 29 U.S.C. Section
1003(b)(1). To qualify, the TPA shall
administer exclusively
(100%) self-funded governmental plans
only. The applicant shall attach a list
of plans it is
administering. See RSA 402-H:1 I.
_____ A person licensed as a managing
general agent in this state, pursuant to RSA 402-E, whose
activities are limited exclusively to
the scope of activities conveyed under such license.
_____ An administrator
who is affiliated with an insurer and who only performs the contractual
duties, between the administrator and
the insurer, of an administrator for the direct and assumed
insurance business of the affiliated
insurer. The insurer is responsible for
the acts of the
administrator and is responsible for
providing all of the administrator's books and records
to the
insurance commissioner, upon request
from the insurance commissioner. For
purposes of this
subparagraph, "insurer" means
a licensed insurance company, prepaid hospital or medical care
plan, or a health maintenance
organization.
_____ An administrator is not required to hold
a certificate of authority as an administrator in this
state if all of
the following conditions are met:
(1) The administrator has its principal place of
business in another state.
(2) The administrator is not soliciting business
as an administrator in this state.
(3) The administrator's New Hampshire business
includes in total fewer than 100 certificateholders.
NOTARIZATION
STATE
of
COUNTY
of
BEFORE
ME, the undersigned authority, personally appeared
_____________________________________ who being duly sworn, stated that all
information contained in the attached application for exception of licensure
is, to the best of his knowledge, true, complete and
correct.
(Witness
Signature) (Authorized
Representative Signature)
(Printed
Name) (Printed
Name)
Sworn
to and subscribed before me this __________ day of _______in the year
____________
(Notary
Public Signature)
(Notary
Public Printed Name)
APPENDIX 3
Form TPA-3 NEW HAMPSHIRE THIRD PARTY
ADMINISTRATOR BOND
BOND
NO. ________
KNOW
ALL MEN BY THESE PRESENTS:
That we, ______________________________________________________________,
as Principal, and
_____________________________________________________________________as
Surety, are held and firmly bound unto,
_____________________________________________ Commissioner of Insurance for the
State of New Hampshire and his successors in office, for the use and benefit of
the State of New Hampshire and the citizens thereof, in the sum of
_______________________________________________ dollars, lawful money of the
United States, for the payment of which well and truly to be made, we hereby
bind ourselves, our successors and assigns, jointly, severally and firmly by
these presents.
WHEREAS
the said Principal has applied to the Commissioner of Insurance of the State of
New Hampshire to be licensed as a Third Party Administrator in the State of New
Hampshire as prescribed in New Hampshire Revised Statutes Annotated RSA 402-H
and as required by Regulations Ins 2300 of the New Hampshire Insurance
Department to give bond unto the Commissioner of Insurance for the State of New
Hampshire to guarantee the payment of all claims or other legal obligations
which the Principal fails to pay, up to the amount of this bond, which arise
from the operations of the Principal in the State of New Hampshire.
NOW,
THEREFORE, this bond shall continue in full force and effect until terminated
in the following manner. This bond may be cancelled by the Insurance
Commissioner for the State of New Hampshire by written notice from the
Insurance Commissioner to the Surety hereon, which notice shall specify the
date of termination of the bond.
Cancellation
by the Surety Company shall not be effective until 90 days following receipt of
written notice to the Insurance Commissioner and Principal.
IN
WITNESS WHEREOF, the parties herein have caused this bond to be executed this
_______
day
of , 20 .
(Witness) (Principal)
By:
(Witness) By:
APPENDIX A
Rule
|
Statute
|
|
|
|
|
Ins 2301.01 |
RSA 402-H |
|
Ins 2301.02 |
RSA 402-H:2 |
|
Ins 2301.03 |
RSA 400-A:15, I; RSA 402-H:11 |
|
Ins 2301.04 |
RSA 402-H:9,
10 |
|
Ins 2301.05 |
RSA 402-H:11,
VIII |
|
Ins 2301.06 |
RSA
402-H:11,12 |
|
Ins 2301.07 |
RSA 402-H:11 |
|
Ins 2301.08 |
RSA 402-H:7,9 |
|
Ins 2301.09 |
RSA 402-H:7 |
|
Ins 2301.10 |
RSA 402-H:7 |
|
Ins 2301.11 |
RSA 402-H:7 |
|
Ins 2301.12 |
RSA 402-H:7 |
|
Ins 2301.13 |
RSA 402-H:4 |
|
Ins 2301.14 |
RSA 402-H:13 |
|
Ins 2301.15 |
RSA 402-H:6 |
|
Ins 2301.16 |
RSA 402-H:5 |
|
Ins 2301.17 |
RSA 402-H:14 |
|
Ins 2301.18 |
RSA 402-H:15 |
|
Ins 2301.19 |
RSA 402-H:15 |
|
Ins 2301.20 |
RSA 402-H:16 |
|
Appendix 1 |
RSA 400-A:15,
I; RSA 402-H:11 |
|
Appendix 2 |
RSA 400-A:15, I,
RSA 402-H:1, I |
|
Appendix 3 |
RSA 400-A:15,
I |