N.H. Admin. Code Ins, ch. Ins 2300, pt. Ins 2301, app 2

Form TPA-2 Authorization of Exception

I. REQUEST for an EXCEPTION from LICENSURE

as a THIRD PARTY ADMINISTRATOR

in New Hampshire

Certain persons or entities are 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 person or entity. 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.

EXCEPTED PERSON OR ENTITY NAME:

The above named excepted person or entity 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 New Hampshire business includes in total fewer than 100 certificateholders.

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)

Notes

N.H. Admin. Code Ins, ch. Ins 2300, pt. Ins 2301, app 2