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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 .
 Fillable pdf Last Modified 3/18/2014
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FORM-SI-TPA OKLAHOMA WORKERS' COMPENSATION COMMISSION 1915 NORTH STILES AVENUE OKLAHOMA CITY, OKLAHOMA 73105 (405) 522-3222 or In-State Toll Free (800) 522-8210 APPLICATION FOR THIRD-PARTY ADMINISTRATOR PERMIT Date:_____________________ The undersigned, a company providing Third-Party Administrative services to Own Risk employers and/or Group SelfInsurance 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. TPA Name________________________________________________________________________________ 2. Desired effective date (application should be submitted 30 days in advance)_____________________________ 3. TPA # (if a renewal applicant)_________________________________________________________________ 4. Name of Parent Company, if applicable__________________________________________________________ 5. Home office address, phone number & e-mail address_______________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ 6. Oklahoma office address, phone number & e-mail address:___________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ 7. Years in business (nationally)__________________________________________________________________ 8. Years in business (in Oklahoma)________________________________________________________________ 9. A nonrefundable application fee of $1,000, made payable to the Oklahoma Workers' Compensation Commission, must be included with the application. 10. Please include the following items with the application: a. b. Current financial statements, including balance sheet and income statement. Names of all claims adjusters on staff. Please include a photocopy of the current Oklahoma license for each adjuster. Form-SI-TPA, Page 1 of 3 American LegalNet, Inc. www.FormsWorkFlow.com c. d. e. Names and a brief resume of each claims manager, or equivalent supervisory personnel. A description of how service fees are determined. 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. A description of how client funds are handled for payment of claims. A copy of any independent audits performed on the applicant in the past 3 years. A description of the applicant's policy for setting reserves. 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. f. g. h. i. j. In consideration of the approval of this application, the applicant hereby expressly agrees to comply with all applicable statutes, and with the Rules of the Workers' Compensation Commission. 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________. ____________________________________________________________________________________________ Print Name & Title (note: person signing should be authorized to bind the applicant to the agreements contained herein) ____________________________________________________________________________________________ Signature ____________________________________________________________________________________________ Mailing Address ____________________________________________________________________________________________ City, State, ZIP ____________________________________________________________________________________________ Telephone ____________________________________________________________________________________________ E-mail Address Administrative Workers' Compensation Act, 85A O.S., ยง6(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. Form-SI-TPA, Page 2 of 3 American LegalNet, Inc. www.FormsWorkFlow.com Send application to: Insurance Division Oklahoma Workers' Compensation Commission 1915 N Stiles Avenue Oklahoma City, OK 73105-4918 Form-SI-TPA, Page 3 of 3 American LegalNet, Inc. www.FormsWorkFlow.com
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