CHAPTER
Ins 2300 THIRD PARTY ADMINISTRATORS
Statutory
Authority: RSA 400-A:15; 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
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
Ins 2301.03 Application.
(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, or 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)
The completed form shall contain:
(1) The administrator’s name;
(2) The administrator’s trade name, if used;
(3) The name of the insurer or person whose
business is being administered;
(4) The administrator’s business address;
(5) The name of the administrator’s department
contact person;
(6) The title of the administrator’s department
contact person;
(7) The address of the administrator’s department
contact person;
(8) The telephone number of the administrator’s
department contact person;
(9) A description of the administrator’s
responsibilities under the contract with the insurer or employer, including:
a. Solicitation of coverage;
b. Underwriting;
c. Collection of charges/premium;
d. Claims adjustment;
e. General management services
f. Distribution of advertising materials;
g. Claims payment; and
h. An explanation of any other services
provided;
(10) The effective date of the administrator’s
contract with the insurer or other person;
(11) The physical location of the books and
records maintained by the administrator pursuant to the contract with the
insurer or other person;
(12) The coverage amounts, terms and identity of
the carrier of any reinsurance in effect or to be carried for the benefits to
policyholders administered by the contract;
(13) An executed copy of the administrator’s contract
with the insurer or other person;
(14) The identity of the insurer or other person
to the contract and services provided by the administrator under any other
contract whether in this state or any other state;
(15) The identity of all individuals or entities
who are responsible for the conduct of the affairs of the administrator
including:
a. All members of the board of directors,
trustees, executive committee or other governing board or committee;
b. The principal officers in the case of a corporation;
c. The partners in the case of a partnership or
association;
d. Shareholders holding, directly or indirectly,
10 percent or more of the voting securities of the administrator; and
e. Any other person who exercises control or
influence over the affairs of the administrator.
(16) An attached biographical affidavit from each
person responsible for the conduct of the affairs of the administrator
including:
a. Name;
b. Current address;
c. Official position;
d. Professional qualifications; and
e. Any conviction of a crime other than minor
traffic violations in the past 10 years;
(17) An attached copy of the notification to be
sent to the insurer’s policyholders informing them of the administrator’s
contracted services;
(18) An attached copy of all advertising and
marketing materials to be distributed by the administrator prior to
distribution of any such materials;
(19) An attached copy of all basic organizational
documents of the administrator including any articles of incorporation,
articles of association, partnership agreement, trade name certificate, trust
agreement, shareholder agreement and all amendments to such documents;
(20) An attached copy of the bylaws, rules,
regulations or similar documents regulating the internal affairs of the
administrator;
(21) An attached copy of the audited financial
statements which reflect the solvency of the administrator by a certified
public accountant for the 2 most recent years, including the opinion of the CPA
and all notes to the statements;
(22)
An attached statement describing the
business plan, including information of staffing levels and activities to be
performed in this state and nationwide under the contract including:
a. Details describing the administrator’s
capability to perform the contracted services; and
b. Sufficient experienced and qualified
personnel for such services as underwriting, claims processing and record
keeping;
(23) If the administrator shall be managing the
solicitation of new or renewal insurance policies, attach documentation to the
application that clarifies whether the administrator is, or has employed or
contracted with a producer licensed by this state for solicitation and taking
of applications;
(24) If the administrator is not an individual and
intends to directly solicit insurance contracts or to otherwise act as an
insurance agency, attach
documentation to the application demonstrating licensing in the state; and
(25) An affidavit by an officer of the insurer
attached to the contract pursuant to Ins 2301.03 (c)(13).
(d)
The exception registration shall contain:
(1) The administrator’s name;
(2) The administrator’s trade name, if used;
(3) The name of the insurer or person whose
business is being administered;
(4) The administrator’s business address;
(5) The name of the administrator’s department
contact person;
(6) The title of the administrator’s department
contact person;
(7) The address of the administrator’s department
contact person;
(8) The telephone number of the administrator’s
department contact person;
(9) The reason or reasons for which an exception
is claimed; and
(10) An affidavit of the administrator’s
authorized representative pursuant to Ins 2301.03 (d)(9) above.
(e)
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.
(f)
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.
(g)
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.
(h)
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.
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
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
Ins 2301.05 Surety Bond.
(a)
An administrator that administers benefit plans for an insurer that is
not licensed in
(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
(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
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
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
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
Ins 2301.09 Establishment of Premium Trust Account.
(a)
Each TPA that collects premium or return premiums shall establish a
premium trust account for
(b)
If the account is interest bearing, the requirements of Ins 2301.11
shall be observed.
(c)
Fiduciary funds on
(d)
The TPA's
(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
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
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
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
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
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
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 report 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
Ins 2301.15 Responsibilities of the Insurer.
(a)
The insurer shall be responsible for determining benefits, premium
rates, underwriting criteria and claims payment procedures 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
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
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
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
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
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 alleged 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
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
Annual Report Filing Fee
(RSA 400-A:29 III.) $100.00
(Due March 1st of
each year following licensure)
Annual Renewal (RSA 400:29
(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
· A
surety bond issued for a minimum of $100,000.00 by a surety company licensed to
do business in the State of
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
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
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)
Ins
2300 Appendix 2
Form
TPA-2 Authorization of Exception
as a THIRD PARTY ADMINISTRATOR
in
An administrator is 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 administrator. 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.
ADMINISTRATOR NAME:
The above named
administrator 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
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)
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
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
Rule
|
Statute
|
|
|
|
|
Ins
2301.01 |
RSA
402-H |
|
Ins
2301.02 |
Ins
402-H:2 |
|
Ins
2301.03 |
Ins
402-H:11 |
|
Ins
2301.04 |
Ins
402-H:9, 10 |
|
Ins
2301.05 |
Ins
402-H:11 |
|
Ins
2301.06 |
Ins
402-H:11,12 |
|
Ins
2301.07 |
Ins
402-H:11 |
|
Ins
2301.08 |
Ins
402-H:7,9 |
|
Ins
2301.09 |
Ins
402-H:7 |
|
Ins
2301.10 |
Ins
402-H:7 |
|
Ins
2301.11 |
Ins
402-H:7 |
|
Ins
2301.12 |
Ins
402-H:7 |
|
Ins
2301.13 |
Ins
402-H:4 |
|
Ins
2301.14 |
Ins
402-H:13 |
|
Ins
2301.15 |
Ins
402-H:6 |
|
Ins
2301.16 |
Ins
402-H:5 |
|
Ins
2301.17 |
Ins
402-H:14 |
|
Ins
2301.18 |
Ins
402-H:15 |
|
Ins
2301.19 |
Ins
402-H:15 |
|
Ins
2301.20 |
Ins
402-H:16 |
|
Appendix
1 |
Ins
402-H:11 |
|
Appendix
2 |
Ins
402-H:11 |
|
Appendix
3 |
Ins
402-H:11 |
|
|
|