Fillable New Renewal (Arizona)

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New Renewal (Arizona)

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TPA Registration Application Checklist
Form E-200 (v. 20161114) Page 1 of 2
Type of Application
New Renewal
Name of TPA
AZ #
DBA Name of TPA, if applicable
Name of analyst
Date application received
Date review completed
Application Decision
Approve Deny (reason for denial):
Decided by: Decision date: Communication date:
Requirement Statute N/A Meets Fails
1
$195 fee
20-485.12.B
2
Application Form E-100
20-485.12.B
a.
SECTION A: Applicant is organized in good
standing with the appropriate government agency
20-485.12.B.2
20-485.12.F
b.
ALL: Every question on the application is
answered
20-485.12.B.7
20-485.12.B.10
c.
SECTION F: The affidavit/attestation is complete
and is signed by officer(s) of the applicant.
20-485.12.B.10
d.
SECTION C, Item 6: Arizona monies, to be
handled in the next/were handled during preceding,
calendar year
20-485.12.B.1.a $
e.
SECTION D, Items 1 or 3: If YES, explanation
and documentation enclosed
f.
SECTION E, Item 3: If NO, enter N/A. If YES,
applicant provided Form E-100-A (Yes or No) and
all are complete.
20-485.12.B.6
g.
SECTION E, Item 9: If NO, enter Meets. If YES,
enter Fails.
h.
SECTION E, Items10/11: If NO, enter N/A. If
either are YES, applicant provided complete
holding company system chart (Yes or No).
20-485.B.3
i.
SECTION E, Item13: Number of biographical
affidavits provided match the reported count
20-485.12.B.5
j. Each biographical affidavit is fully completed, and
information is consistent with NAIC RIRS/SAD and
other information sources.
k. For each biographical affidavit with a YES answer
to a background question (NAIC Form 11, Item 11),
application includes a copy of the complaint and
the filed adjudication/settlement for each matter.
Reset
TPA Registration Application Checklist
Form E-200 (v. 20161114) Page 2 of 2
Requirement Statute N/A Meets Fails
3
Financial information for a period ending within 90
days of the application submission date and/or
calendar year end
20-485.12.B.1
a. Financial statements have been certified by officer(s) of the applicant
b.
Applicant provided non-consolidated GAAP income statements for the
two preceding years
c.
Net Income – Current Income Statement
= SECTION C, Item 1
$
d.
Applicant provided non-consolidated GAAP balance sheets for the two
preceding years
e.
Current Assets – Current Balance Sheet
= SECTION C, Item 2
$
f.
Current Liabilities – Current Balance Sheet
= SECTION C, Item 3
$
g.
Working Capital – Current Balance Sheet
= SECTION C, Item 4
$
h.
Owner’s Equity – Current Balance Sheet
= SECTION C, Item 5
$
i. If the net income, working capital or owner/stockholder equity is
negative, applicant included mitigation explanation
4
Trust deposit by
Certificate of Deposit Marketable securities Surety bond
a.
=
20-485.10
$
b.
$
c.
or schedule or blanket forms of bonds):
NAIC# ________
of
AZ-authorized insurer
Yes No Form 157
Yes No Attorney-in-Fact
d.
Yes
No
Form E125CD
Yes No Two E150s forms
Yes
No
Original CD
e.
Yes
No
Custody Agreement
Yes
No
Form E125
5
The details about the applicant’s capacity to collect
premiums or administer claims on behalf of the insurer
in this state have been provided
20-485.12.B.8
6
Basic organization documents and amendments,
including articles of incorporation, articles of
association, partnership agreement, trade name
certificate
20-485.12.B.2
7
The bylaws, rules, regulations or similar
documents
20-485.12.B.4
8
The written notice that the TPA will provide to
insured individuals providing the TPA's identity and
the relationship between the TPA and the insurer
20-485.B.12.9
0
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New Renewal (Arizona)

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Completed 1 July 2022

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