Fillable SURRENDER OF THIRD PARTY ADMINISTRATOR CERTIFICATE OF AUTHORITY (Department of Technology and Information)

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SURRENDER OF THIRD PARTY ADMINISTRATOR CERTIFICATE OF AUTHORITY (Department of Technology and Information)

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BROWSE DEPARTMENT OF TECHNOLOGY AND INFORMATION (DE) FORMS

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STATE OF DELAWARE
DEPARTMENT OF INSURANCE
OFFICE OF THE
COMMISSIONER
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.
T
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.
______________________________
Signature
______________________________
Printed Name
______________________________
Company Address
______________________________
City, State, Zip
______________________________
Area Code and Phone No.
______________________________
Email address
1351 West North Street, Dover, DE 19904 •
insurance.delaware.gov
(302) 674-7300 Dover • (302) 739-5280 fax • (302) 577-5280 Wilmington
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SURRENDER OF THIRD PARTY ADMINISTRATOR CERTIFICATE OF AUTHORITY (Department of Technology and Information)

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Completed 13 August 2020

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