Fillable THIRD PARTY ADMINISTRATOR AFFIDAVIT OF EXEMPTION (Department of Technology and Information)

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THIRD PARTY ADMINISTRATOR AFFIDAVIT OF EXEMPTION (Department of Technology and Information)

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U.S.A. forms for Department of Technology and Information

BROWSE DEPARTMENT OF TECHNOLOGY AND INFORMATION (DE) FORMS

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1351 West North Street, Dover, DE 19904 •
insurance.delaware.gov
(302) 674-7300 Dover • (302) 739-5280 fax • (302) 577-5280 Wilmington
STATE OF DELAWARE
DEPARTMENT OF INSURANCE
OFFICE OF THE
COMMISSIONER
THIRD PARTY ADMINISTRATOR
AFFIDAVIT OF EXEMPTION
I do hereby swear and affirm that _____________________________________ maintains a valid Third
Company Name
Party Administrator (TPA) license from ____________________.
State of Domicile
__________________________________________ represents fewer than 100 lives within the State of
Company Name
Dela
ware and, therefore, is exempt from 18 Del. Admin. C. 1406.
Should the number of lives increase to 100 or
more, we will notify the Delaware Department of Insurance and complete the required TPA application for
licensure.
____________________
______________________
Signature/Date
Printed Name: ______________________________
Title: _____________________________________
Address: _________________________________________________
Phone: _________________________
Email: ___________________________________
SWORN TO AND SUBSCRIBED before me this _____ day of _________________, 20____.
_____________________________________________
Notary Public
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THIRD PARTY ADMINISTRATOR AFFIDAVIT OF EXEMPTION (Department of Technology and Information)

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Completed 13 August 2020

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