Fillable Form E-115: Life and Health (Third-party) Administrator Information (Arizona)

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Form E-115: Life and Health (Third-party) Administrator Information (Arizona)

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Form E-115 (v 20201031) Page 1 of 3
Email: TPAinformation@difi.az.gov
Form E-115: Life and Health (Third-party) Administrator Information Update
SECTION A: Information Update
Department Use:
Please complete this form on your computer; then print it, sign it and submit it.
This form requests “OLD” information and “NEW” information.
OLD information means the information that the TPA last reported to the Arizona Department of
Insurance and Financial Institutions (“DIFI”).
NEW information means information that is now different from OLD information. Only complete NEW information fields if information
changed from what was previously filed with the DIFI. NEW information provided on this form must be consistent with information
maintained by the appropriate government agency (i.e. Arizona Corporation Commission, Arizona Secretary of State, county recorder
office). It is critical that you update information with the other agency before filing updated information with the DIFI.
(*required) means you must enter the requested information.
1. Type of change (*required):
Legal Name
DBA Name
Address/Phone/Fax
Officer and/or Director Ownership or Control
2. AZ TPA Registration Number (*required):
3. Effective Date of Change (*required):
4a. OLD (Legal) Name (*required)**:
4b. NEW (Legal) Name**
(must be reflected on the ACC web site)
:
**If the TPA changed its legal name, you must enclose with this form the documents specified in SECTION C.
5a. OLD DBA Name (if applicable):
5b. NEW DBA Name (if applicable):
6a. OLD Mailing Address (*required):
6b. NEW Mailing Address:
7a. OLD Main Administrative Office Address:
7b. NEW Main Administrative Office Address:
8a. OLD Area Code and Phone Number
8b. NEW Area Code and Phone Number
9a. OLD Toll-free Telephone Number
9b. NEW Toll-free Telephone Number
10a. OLD Fax Number
10b. NEW Fax Number
SECTION B: Contact Information
Contact Person – Name (*required):
Title:
E-mail Address (*required):
Phone Number (*required):
Reset
AZ TPA Registration Number:
TPA (Legal) Name
Form E-115: Life and Health (Third-party) Administrator Information Update (v 20201031) Page 2 of 3
SECTION C: Enclosures for a LEGAL NAME CHANGE
Submit the following SECTION C items only if the TPA changed its legal name in Section A, Items 4a and 4b:
1. ENCLOSE deposit documentation that is in the NEW name:
a. Surety bond: ENCLOSE Form E-157 and an Attorney-in-Fact.
OR
b. Certificate of deposit (CD): ENCLOSE ►one E-125-CD form (if a new CD was issued) AND ►two E-150
forms and ►the original of the CD (if a new CD was issued).
OR
c. Marketable security: ENCLOSE a copy of name change email notification to Union Bank at
arizona-union@unionbank.com.
2. ENCLOSE the TPA’s AMENDED basic organization documents, including articles of incorporation/association,
partnership agreement, trade name certificate, trust agreement, shareholder agreement, etc. ARS § 20-
485.12(B)(2)
3. ENCLOSE the TPA’s AMENDED bylaws, regulations or similar documents that regulate the administrator’s affairs.
ARS § 20-485.12(B)(4)
SECTION D: Enclosures for OFFICER AND/OR DIRECTOR CHANGES
Submit the following SECTION D items within 30 days after the change becomes effective only if the TPA changed its
officers and/or directors:
1. ENCLOSE Form E-100-B to report the name and title of each “individual responsible for the administrator’s affairs”
for whom an NAIC Biographical Affidavit Form 11 was not previously submitted to the Arizona Department of
Insurance by the applicant.
“Individuals responsible for the administrator’s affairs” include:
• All members of the board of directors/trustees, members of the executive committee or any other governing
board of the committee, PLUS
• If applicant is a corporation, all officers and all shareholders that directly or indirectly hold at least 10% of the
voting securities of the applicant if a corporation, AND
• If applicant is a partnership or association, all partners.
ENCLOSE an NAIC Biographical Affidavit Form 11 for each individual listed on Form E-100-B.
ARS § 20-485.12(B)(5).
IMPORTANT! The Department will investigate information provided and may deny a license if the applicant fails to
provide complete and truthful information about itself and the individuals responsible for the administrator’s affairs.
2. Did any NAIC Biographical Affidavit Form 11 submitted with this application contain a “Yes” response to
one or more question in Item 11? ARS § 20-485.12(B)(5)
YES. ENCLOSE a copy of the complaint and the filed adjudication or settlement for each matter.
NO.
AZ TPA Registration Number:
TPA (Legal) Name
Form E-115: Life and Health (Third-party) Administrator Information Update (v 20201031) Page 3 of 3
SECTION E: Enclosures for OWNERSHIP OR CONTROL CHANGE
Submit the following SECTION E items within 30 days after the change becomes effective only if the TPA had an
ownership or control change:
Section E, Items 1 and 2 are purposely omitted.
3. Does the applicant use any name or have any office other than those previously reported to the Arizona
Department of Insurance?
YES. ENCLOSE Form E-100-A to report the applicant’s complete name and address for all offices in each
jurisdiction (ARS § 20-485.12(B)(6)).
NO. You do not need to complete Form E-100-A.
Section E, Items 4 through 8 are purposely omitted.
9. Describe the change to the administrator’s ownership or control.
10. Is the administrator owned by another entity that directly or indirectly controls the applicant?
ARS § 20-485.12(B)(3)
YES NO
11. Does the administrator directly or indirectly control any affiliate entity? ARS § 20-485.12(B)(3)
YES NO
You answered “YES” to Item 1 or Item 2. ENCLOSE a holding company system chart that shows the parent/child/sibling
relationships among each holding company system member, including each affiliate that directly or indirectly controls the
applicant and every affiliate the applicant directly or indirectly controls.
SECTION F (*required): AFFIDAVIT of an officer of the TPA authorized by the TPA to verify the facts stated on this
form.
I, ________________________________________________________________ (name of Officer) being duly sworn,
depose and say that I am the ________________________________________________________ (title of Officer) of
________________________________________________________________________________ (name of TPA)
AND that I am duly authorized to bind the TPA,
AND that all information provided in all sections of this form and in all enclosures herewith are true and correct to the
best of my knowledge and belief,
AND that I understand any misrepresentation or omission of a material fact on this form or the enclosures herewith is a
ground for denial or revocation of the Certificate of Registration.
I acknowledge that I am familiar with the insurance laws and regulations of the State of Arizona, including but not limited
to Arizona Revised Statutes Title 20, Chapter 2, Article 9 (ARS § 20-485 et seq.), and I shall comply with the laws of the
State of Arizona.
_______________________________________________ ________________
Signature Date
Submit the application and enclosures using the TPA Portal (https://azinsurance.online/Upload/tpa
Submit the application and enclosures using the TPA Portal (https://azinsurance.online/Upload/tpa)
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Form E-115: Life and Health (Third-party) Administrator Information (Arizona)

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Completed 1 July 2022

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