Arkansas > Workers Comp
Third Party Administrator Application Or Registration TPA - Arkansas
| Third Party Administrator Application Or Registration Form. This is a Arkansas form and can be used in Workers Comp . |
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Form TPA Eff. 11/01/2001 Ark. C ode Ann. 11-9-302 (b) and AWC C Rule 38 ARKANSAS WORKERS' COMPENSATION COMMISSION TPA ADMINISTRATION 324 Spring Street, Little Rock, AR 72201 Mail: P. O. Box 950, Little Rock, AR 72203-0950 501-682-2783 / 1-800-622-4472 TPA Date_______________________ THIRD PARTY ADMINISTRATOR Application / Registration Form 1. 2. 3. 4. 5. 6. 7. 8. 9. Applicant (legal) name: ____________________________________________________________________________ Federal Employer Identification Number (FEIN): _______________________________________________________ Applicant trade name / DBA name: __________________________________________________________________ Applicant home office address: _____________________________________________________________________ Applicant main phone # ___________________________________ Applicant toll free # ________________________ Applicant is: G Corporation, G Partnership, G Individual, G Other (specify) ________________________________ Applicant home office contact person: ________________________________________________________________ Applicant home office contact person address: __________________________________________________________ Applicant home office contact direct phone #: __________________________________________________________ Fax #: _________________________________ E-Mail Address: __________________________________________ 10. Indicate the desired effective date for Third Party Administrator approval _____________________________________ 11. As a TPA, will you handle Arkansas claims for: 9 Carrier Clients? 9 Self-Insured Clients? 9 Or both? 12. If handling claims for self-insured clients, please list the personnel that will be providing services in the following areas and submit resumés for those people: Claims: _________________________________________________________________________________________ _______________________________________________________________________________________________ ________________________________________________________________________________________________ Underwriting: ____________________________________________________________________________ _________________________________________________________________________________________________ ________________________________________________________________________________________________ Loss Control: ____________________________________________________________________________________ _____________________________________________________________________________________________ ________________________________________________________________________________________________ Page 1 of 3 American LegalNet, Inc. www.USCourtForms.com Form TPA (Eff 11/1/01) 13. Complete the following for each additional location (if the claim manager or address is different from the home office contact person above) of the company in which Arkansas claims will be handled (attach additional pages if necessary. You may copy this page and include it with the application): Location Name: ___________________________________________________________________________ Claim Manager: ___________________________________________________________________________ Location Address: _________________________________________________________________________ Location City: ______________________________ Location State: ______ Location Zip: _____________ Location Phone: _____________________ Location Fax: __________________ Location Name: ___________________________________________________________________________ Claim Manager: ___________________________________________________________________________ Location Address: _________________________________________________________________________ Location City: ______________________________ Location State: ______ Location Zip: _____________ Location Phone: _____________________ Location Fax: __________________ Location Name: ___________________________________________________________________________ Claim Manager: ___________________________________________________________________________ Location Address: _________________________________________________________________________ Location City: ______________________________ Location State: ______ Location Zip: _____________ Location Phone: _____________________ Location Fax: __________________ Location Name: ___________________________________________________________________________ Claim Manager: ___________________________________________________________________________ Location Address: _________________________________________________________________________ Location City: ______________________________ Location State: ______ Location Zip: _____________ Location Phone: _____________________ Location Fax: __________________ Page 2 of 3 American LegalNet, Inc. www.USCourtForms.com Form TPA (Eff 11/1/01) This application is to be completed and sent along with the application fee of one hundred dollars ($100) payable to the Arkansas Workers' Compensation Commission, P. O. Box 950, Little Rock, AR 72203-0950. I certify that the information submitted with this application is true and correct to the best of my knowledge. Further, I agree to update any change in locations, location personnel or report any data material to this application to the Commission as the need may arise. _____________________________________________________________ Legal Name of Applicant _____________________________________________________________ Name(Print) of authorized official of Applicant _____________________________________________________________ Title of official _____________________________________________________________ Signature of Official ______________________________________________________________ Date State of ______________________ County of ______________________A Subscribed and sworn to before me by _________________________________________________________________ on this __________ day of ______________________, 2 ______. (Seal) _____________________________________ Notary Public My commission expires: _________________________________. Page 3 of 3 American LegalNet, Inc. www.USCourtForms.com Form TPA (Eff 11/1/01)
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