N.H. Admin. Code Ins, ch. Ins 2300, pt. Ins 2301, app 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)) $300.00

Annual Report Filing Fee (RSA 400-A:29 III.) $100.00

(Due March 1^st of each year following licensure)

Annual Renewal (RSA 400:29 I.(c)) $ 100.00

(Due June 14^th 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)

Notes

N.H. Admin. Code Ins, ch. Ins 2300, pt. Ins 2301, app 1