Fillable State of New Hampshire (State of New Hampshire)

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State of New Hampshire (State of New Hampshire)

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BROWSE STATE OF NEW HAMPSHIRE (NH) FORMS

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WC-TPA-CBP (3/2019) Page 1
State of New Hampshire
Department of Labor
NOTICE OF CONTRACT
BETWEEN THIRD PARTY ADMINISTRATOR AND SELF-INSURER
ADMINISTRATOR NAME:____________________________________________________
TRADE NAME (If used):_______________________________________________________
ADDRESS:__________________________________________________________________
___________________________________________________________________
NAME OF INSURER:_________________________________________________________
ADDRESS:__________________________________________________________________
__________________________________________________________________
CONTACT NAME:___________________________________________________________
CONTACT TITLE:________________________PHONE_____________________________
CONTACT ADDRESS_________________________________________________________
_________________________________________________________
Under the terms of the attached contract, the administrator will be responsible for: (Check those which
apply)
_________Solicitation of Coverage __________Underwriting
_________Collection Charges/Premiums __________Claims adjustment
_________Distribution Ad Materials __________General Management Services
_________Claims Payment __________Other (Explain)
Effective Date of Contract:______________________________________________________
Physical location of books and records maintained by the administrator in regard to this
agreement:___________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
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
WC-TPA-CBP (3/2019) Page 2
Also include the following items:
A copy of the contract between the administrator and insurer.
A copy of the notification which will be sent to policyholders informing them of this arrangement.
_______________________________________________________
Signature of Representative
_______________________________________________________
Signature of Self-Insurer Representative
_______________________________________________________
Printed Name of Administrator Representative
_______________________________________________________
Printed Name of Self-Insurer Representative
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State of New Hampshire (State of New Hampshire)

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Completed 21 July 2020

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