Fillable TPA / Claims Administrators Supplement (Risk Placement Services, Inc.)

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TPA / Claims Administrators Supplement (Risk Placement Services, Inc.)

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QBE and the links logo are registered service marks of QBE Insurance Group Limited
QBPC 30 04 09 15 Page 1 of 2
Applicant information
Full name of applicant
1. Please advise the percentage of gross annual premium derived from the following
TPA
Claims administration
Claims Adjustment
%
%
%
2. What lines of insurance do these professional services involve and for which insurance carriers?
Lines
Carrier
3. Does the firm have Draft Authority?
Yes
(a) If yes, advise the amount of first party authority
(b) Third party authority
$
$
(c) Is the authority defined in writing?
Yes
No
(d) If no, please explain
4. Describe your procedures for making payments on claim files
5. Are you required to alert the carrier in writing of all policy limit demands or demands
beyond your authority?
Yes
No
If no, please explain
6. How often do the carriers conduct audits?
Yearly
Semi Annual
Quarterly
Other
(a) Have there been any restrictions to your authority as a result of audits?
Yes
No
(b) If yes, provide complete details
7. What is the average caseload per claims handler on an annual basis?
Number of claims/handlers?
(a) How is the caseload monitored and managed?
TPA / Claims Administrators Supplement
QBPC 30 04 09 15 Page 2 of 2
8. Does the firm have HIPAA compliance policies and procedures?
Yes
No
(a) Provide a copy of the procedures. If no, provide explanation.
9. How does the firm protect confidential information?
10. Does the firm follow Best Claim Handling Guidelines?
Yes
No
If yes, have they been provided by the particular insurance carriers, or are they internal guidelines?
Please describe the above, or provide copies of guidelines.
If no, please explain
Signatures
I understand information submitted herein becomes a part of my Insurance Agents & Brokers Errors and Omissions
Application and is subject to the same representation and conditions.
*Signing this form does not bind the applicant or the Company or the Underwriting Manager to complete the insurance.
Applicant's name*
Title
Applicant’s signature
Date
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signature
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TPA Claims Administrators Supplement (Risk Placement Services, Inc.)

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Completed 30 July 2020

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