Fillable TPA Registration Application Checklist (Arizona)

Fill Online, Printable, Fillable, Blank TPA Registration Application Checklist (Arizona) Form

Use Fill to complete blank online ARIZONA pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

TPA Registration Application Checklist (Arizona)

On average this form takes 27 minutes to complete

The TPA Registration Application Checklist (Arizona) form is 2 pages long and contains:

  • 0 signatures
  • 6 check-boxes
  • 107 other fields

Country of origin: US
File type: PDF

BROWSE ARIZONA FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
TPA Registration Application Checklist
Form E-200 (v. 20160706) Page 1 of 2
Type of Application
New Renewal
Name of TPA
AZ #
DBA Name of TPA, if applicable
Name of analyst
Date application received
Date review completed
Application Decision
Decided by:
Decision date:
Communication date:
Requirement
Statute
N/A
Meets
Fails
1
$195 fee
20-485.12.B
2
Application Form E-100
20-485.12.B
a.
SECTION A: Applicant holds an ACC Certificate of
Good Standing and the name exactly matches
ACC record (http://ecorp.azcc.gov/Search)
20-485.12.B.2
20-485.12.F
b.
ALL: Every question on the application is
answered
20-485.12.B.7
20-485.12.B.10
c.
SECTION F: The affidavit/attestation is complete
and is signed by officer(s) of the applicant.
20-485.12.B.10
d.
SECTION C, Item 6: Arizona monies, to be
handled in the next/were handled during preceding,
calendar year
20-485.12.B.1.a
$
e.
SECTION D, Items 1 or 3: If YES, explanation
and documentation enclosed
f.
SECTION E, Item 3: If NO, enter N/A. If YES,
applicant provided Form E-100-A (Yes or No) and
all are complete.
20-485.12.B.6
g.
SECTION E, Item 9: If NO, enter Meets. If YES,
enter Fails.
h.
SECTION E, Items10/11: If NO, enter N/A. If
either are YES, applicant provided complete
holding company system chart (Yes or No).
20-485.B.3
i.
SECTION E, Item13: Number of biographical
affidavits provided match the reported count
20-485.12.B.5
j.
Each biographical affidavit is fully completed, and
information is consistent with NAIC RIRS/SAD and
other information sources.
k.
For each biographical affidavit with a YES answer
to a background question (NAIC Form 11, Item 11),
application includes a copy of the complaint and
the filed adjudication/settlement for each matter.
Reset
TPA Registration Application Checklist
Form E-200 (v. 20160706) Page 2 of 2
Requirement
Statute
N/A
Meets
Fails
3
Financial statements for a period ending within 90
days of the application submission date and/or
calendar year end
20-485.12.B.1
a.
Financial statements have been certified by officer(s) of the applicant
b.
Applicant provided non-consolidated GAAP income statements for the
two preceding years
c.
Net Income – Current Income Statement = SECTION C, Item 1
$
d.
Applicant provided non-consolidated GAAP balance sheets for the two
preceding years
e.
Current Assets – Current Balance Sheet = SECTION C, Item 2
$
f.
Current Liabilities – Current Balance Sheet = SECTION C, Item 3
$
g.
Working Capital – Current Balance Sheet = SECTION C, Item 4
$
h.
Owner’s Equity – Current Balance Sheet = SECTION C, Item 5
$
i.
If the net income, working capital or owner/stockholder equity is
negative, applicant included mitigation explanation
4
Trust deposit by Certificate of Deposit Marketable securities Surety bond
a.
Greater of 10% of SECTION C, Item 6 or $5,000
= SECTION E, Item 2
20-485.10
$
b.
Amount of trust deposit (must be at least Line 4a)
$
c.
For a surety bond (may include individual bonds
or schedule or blanket forms of bonds):
NAIC# ________ of AZ-authorized insurer
Yes No Form 157
Yes No Attorney-in-Fact
d.
For a certificate of deposit:
Yes No Form E125CD
Yes No Two E150s forms
Yes No Original CD
e.
For a marketable security:
Yes No Custody Agreement
Yes No Form E125
5
The details about the applicant’s capacity to collect
premiums or administer claims on behalf of the insurer
in this state have been provided
20-485.12.B.8
6
Basic organization documents and amendments,
including articles of incorporation, articles of
association, partnership agreement, trade name
certificate
20-485.12.B.2
7
The bylaws, rules, regulations or similar
documents
20-485.12.B.4
8
The written notice that the TPA will provide to
insured individuals providing the TPA's identity and
the relationship between the TPA and the insurer
20-485.B.12.9
0
5,000
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

TPA Registration Application Checklist (Arizona)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 12 August 2020

Message

View Audit Log
Print With Audit Log
Duplicate Document