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State of New Hampshire (State of New Hampshire)

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State of New Hampshire
Department of Labor
WC- TPA- COA (Revised 06/2019) Page 1 of 3
Hugh J. Gallen
State Office Park
Spaulding Building
95 Pleasant Street
Concord, NH 03301
603/271-3176
TDD Access: Relay NH
1-800-735-2964
FAX: 603/271-6149
http://www.nh.gov/labor
Ken Merrifield
Commissioner
Rudolph W. Ogden, III
Deputy Commissioner
APPLICATION for CERTIFICATE of AUTHORITY
STATE OF NEW HAMPSHIRE
THIRD PARTY ADMINISTRATORS
CHAPTER 161
ADMINISTRATOR NAME: _____________________________________________
TRADE NAME (if any): _________________________________________________
DOMICILE: __________________________________________________________
ADDRESS: ___________________________________________________________
_____________________________________________________________________
FEDERAL ID # ________________________________________________________
CONTACT NAME: _____________________________________________________
CONTACT TITLE: _____________________________________________________
PHONE: _____________________________
CONTACT
ADDRESS: _____________________________________________________________
______________________________________________________________________
Note: This Department will only correspond with the named contact person. This individual may
be in the company or a contracted person such as a consultant.
Fees
Application Examination $200.00
Annual Renewal $100.00
(Due 60 days prior to license expiration)
All checks must be made payable to: Treasurer, State of New Hampshire.
Our review process will not begin until fees are paid. New Hampshire law does not allow for the
payment of fees after the issuance of the license.
State of New Hampshire
Department of Labor
WC- TPA- COA (Revised 06/2019) Page 2 of 3
Hugh J. Gallen
State Office Park
Spaulding Building
95 Pleasant Street
Concord, NH 03301
603/271-3176
TDD Access: Relay NH
1-800-735-2964
FAX: 603/271-6149
http://www.nh.gov/labor
Ken Merrifield
Commissioner
Rudolph W. Ogden, III
Deputy Commissioner
SECTION 1 - MANAGEMENT
1.) OFFICIAL LIST OF ALL INDIVIDUALS responsible for the conduct of affairs of the
administrator. The list should give the name, position occupied, address and the professional
qualifications of each of these individuals. It should also be sworn to as a true and complete list
by the secretary of the administrator. The list shall include:
Board of Directors
Board of Trustees
Executive Committee/Governing Board/Committee
Principal Officers
Shareholders (10% or more)
Others exercising control/influence
SECTION 2 - FINANCIAL
A Security Deposit Agreement from a New Hampshire bank indicating that a minimum of
$100,000 has been placed with that bank and pledged to the Commissioner of Labor of the
State of New Hampshire,
Or
Fidelity bond with a minimum face value of 1 million dollars.
Or
A surety bond issued for a minimum of $100,000 by a surety company licensed to do
business in the State of New Hampshire.
1.) THE PHYSICAL ADDRESS WHERE THE BOOKS AND RECORDS MAINTAINED
BY THE ADMINISTRATOR ARE LOCATED:
2.) THE FOLLOWING DOCUMENTS MUST BE INCLUDED WITH THE APPLICATION:
Federal Tax Returns (last 3 years)
Audited Financial statement (2 most recent years)
State of New Hampshire
Department of Labor
WC- TPA- COA (Revised 06/2019) Page 3 of 3
Hugh J. Gallen
State Office Park
Spaulding Building
95 Pleasant Street
Concord, NH 03301
603/271-3176
TDD Access: Relay NH
1-800-735-2964
FAX: 603/271-6149
http://www.nh.gov/labor
Ken Merrifield
Commissioner
Rudolph W. Ogden, III
Deputy Commissioner
SECTION 3 - DOCUMENTARY
1.) CERTIFIED COPIES OF ALL BASIC ORGANIZATIONAL DOCUMENTS, including
Articles of Incorporation, Articles of Association, partnership agreements, trade name certificate,
trust agreement, shareholder agreement, recent certificate of good standing for state of domicile
and for State of New Hampshire and all amendments thereto. These items should be certified by
the proper domiciliary state of official.
2.) COPY OF THE BY-LAWS of the applicant certified as a true and correct copy of the
secretary of the company.
3.) BUSINESS PLAN STATEMENT. Attach a separate sheet outlining the Administrator’s
Business Plan, including staffing levels proposed for New Hampshire and nationwide.
4.) SUMMARY of INSURANCE POLICIES. Attach copies of binder pages from insurance
carriers for Administrator’s:
“Errors & Omissions” Insurance
(Carrier/limits/policy period)
“Directors & Officers” Insurance
(Carrier/limits/policy period)
Any other pertinent coverage’s
(Carrier/limits/policy period)
5.) CURRENT ADJUSTERS LICENSES FOR WORKERS’ COMPENSATION IN NH.
6.) EVIDENCE OF A TOLL-FREE TELEPHONE NUMBER.
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Completed 21 July 2020

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