State of New Hampshire
Department of Labor
WC- TPA- COA (Revised 06/2019) Page 3 of 3
Hugh J. Gallen
State Office Park
95 Pleasant Street
Concord, NH 03301
TDD Access: Relay NH
Rudolph W. Ogden, III
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
“Directors & Officers” Insurance
Any other pertinent coverage’s
5.) CURRENT ADJUSTERS LICENSES FOR WORKERS’ COMPENSATION IN NH.
6.) EVIDENCE OF A TOLL-FREE TELEPHONE NUMBER.