DEPARTMENT OF INSURANCE
SURRENDER OF THIRD PARTY ADMINISTRATOR
CERTIFICATE OF AUTHORITY
Please submit completed form along with original Certificate of Authority/License to:
Company Regulation (BERG)
Delaware Department of Insurance
1351 West North Street, Suite 101
Dover, DE 19904
If original license cannot be located, please submit an Affidavit of Lost License.
hird Party Administrator (TPA): ______________________________________
License Number: _____________
My name is ______________________ (printed name of company representative). I am of sound mind, capable of
making this statement, and have personal knowledge of these facts, which are true and correct.
I hold the office of _______________________ (title) for the above-referenced company, which with the submission
of this completed form, is knowingly and voluntarily surrendering its third party administrator authority. I am duly
authorized by the organization to execute this statement.
The company ceased operations requiring TPA authority approximately ________________ (date). To my knowledge,
all required fees/taxes due to the Department have been paid, and there are no current enforcement cases against the
company. If the company has transferred its business to another TPA, I have confirmed that the new entity is properly
licensed to the Delaware Department of Insurance to engage in the business of a TPA.
City, State, Zip
Area Code and Phone No.
1351 West North Street, Dover, DE 19904 •
(302) 674-7300 Dover • (302) 739-5280 fax • (302) 577-5280 Wilmington
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