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Application For Third Party Administrator Permit Form-SI-TPA - Oklahoma

Application For Third Party Administrator Permit Form. This is a Oklahoma form and can be used in Workers Comp .
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OKLAHOMA WORKERS' COMPENSATION COMMISSION 1915 NORTH STILES AVENUE OKLAHOMA CITY, OK 73105 (405) 522-3222 or In-State Toll Free (855) 291-3612 APPLICATION FOR THIRD PARTY ADMINISTRATOR PERMIT Date__________________________________ The undersigned, a company providing Third-Party Administrative Services to Own Risk employers and/or Group Self-Insurance Associations, hereby applies for permission to act as an approved Third-Party Administrator. To enable the Workers' Compensation Commission to determine the applicant's ability to provide these services, said applicant hereby states the following: 1. 2. 3. 4. 5. TPA Name ________________________________________________________________________________ Desired effective date (application should be submitted 30 days in advance) ___________________________ TPA # (if a renewal applicant) _________________________________________________________________ Name of Parent Company, if applicable _________________________________________________________ Home office address, phone number & e-mail address _____________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ 6. Oklahoma office address, phone number & e-mail address __________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ 7. 8. Years in business: Nationally _______________________ In Oklahoma _______________________________ Please include the following items with the application: a. A nonrefundable $1,000 application fee, payable to the Oklahoma Workers' Compensation Commission. b. Audited financial statements for the most recent fiscal year, including a balance sheet, statement of income, statement of cash flows, and notes. Financial statements may be submitted via email to InsuranceDepartment@wcc.ok.gov or via a cd delivered with the application. c. A list of all claims adjusters on staff. Please include a photocopy of the current Oklahoma license for each adjuster. d. A list of all claims managers or equivalent supervisory personnel. Please include a brief resume for each manager. e. A description of how service fees are determined. f. Services performed by the applicant. If services are provided other than claims adjusting, such as safety consulting, marketing or accounting functions, please provide a brief resume of the principal employee(s) providing these services. g. A description of how client funds are handled for payment of claims. h. A copy of the most recent triennial independent audit performed on the applicant. i. A copy of the Service Organization Controls (SOC) 1 report pursuant to the statement on standards for attestation engagements (SSAE) No. 16, resulting from the most recent independent audit. j. A description of the applicant's policy for setting reserves. Form ­ SI TPA Page 1 of 2 Rev. 09-21-15 American LegalNet, Inc. www.FormsWorkFlow.com k. l. 9. A list of all Own Risk employers, Group Self Insurance associations, and other companies the applicant provides services for. A copy of the applicant's Errors and Omissions policy and fidelity bond. In consideration of the approval of this application, the applicant hereby: a. Expressly agrees to comply with all applicable statutes, and with the Rules of the Workers' Compensation Commission; and b. Certifies that the TPA: 1) Has adequate personnel on staff to handle the volume and type of work; 2) Establishes claims at the most likely outcome, rather than best case; 3) Retains independence when setting claim reserves; and 4) Maintains adequate computerized records and paper claims files on each claim. Administrative Workers' Compensation Act, 85A O.S., §6(A)(1)(a): "Any person or entity who makes any material false statement or representation, who willfully and knowingly omits or conceals any material information, or who employs any device, scheme, or artifice, or who aids and abets any person for the purpose of: (1) obtaining any benefit or payment ... shall be guilty of a felony." Any person who commits workers' compensation fraud, upon conviction, shall be guilty of a felony punishable by imprisonment, a fine or both. I declare under penalty of perjury that I have examined this application and all statements contained herein, and to the best of my knowledge and belief, they are true, correct and complete. Signed this __________ day of _______________________________________, 20________. _____________________________________________________________________________________________ Signature of Authorized Representative (Note: Person signing should have authority to bind the applicant to the agreements contained herein) _____________________________________________________________________________________________ Print Name of Authorized Representative Title of Authorized Representative _____________________________________________________________________________________________ Mailing Address City State Zip Code _____________________________________________________________________________________________ Street Address, if different from Mailing Address City State Zip Code _____________________________________________________________________________________________ E-mail Address of Authorized Representative Telephone Number of Authorized Representative Send application to: OKLAHOMA WORKERS' COMPENSATION COMMISSION INSURANCE SERVICES DIVISION 1915 NORTH STILES AVENUE, SUITE 231 OKLAHOMA CITY, OK 73105 Form ­ SI TPA Page 2 of 2 Rev. 09-21-15 American LegalNet, Inc. www.FormsWorkFlow.com
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