Form AID-LI-TPA "Third Party Administrator Application for Registration" - Arkansas

What Is Form AID-LI-TPA?

This is a legal form that was released by the Arkansas Insurance Department - a government authority operating within Arkansas. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on May 1, 2020;
  • The latest edition provided by the Arkansas Insurance Department;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form AID-LI-TPA by clicking the link below or browse more documents and templates provided by the Arkansas Insurance Department.

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Download Form AID-LI-TPA "Third Party Administrator Application for Registration" - Arkansas

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Rev. 5/20
ARKANSAS INSURANCE DEPARTMENT
LICENSE DIVISION
1 COMMERCE WAY, SUITE 104
LITTLE ROCK, AR 72202
PHONE: 501-371-2750
FAX: 501-683-2604
INSTRUCTIONS FOR THIRD PARTY ADMINISTRATOR
APPLICATION FOR REGISTRATION
1. Applicant must complete the Third Party Administrator Application for Registration, Form AID-LI-TPA, and
submit it to the Arkansas Department with a check the amount of $100.00 The check must be made payable to
the “The State Insurance Department Trust Fund.”
2. A $25,000 Surety Bond, executed by an authorized admitted insurer using the bond form, Form AID-LI-
TPABOND, must be attached to the Application for Registration.
Note: Any applicant operating only pursuant to an administrative services agreement, who does not collect,
receive or remit funds on behalf of the Plan(s), is exempt from the bond requirement. Any applicant performing
services only on behalf of single employer self-funded plans or collectively bargained plans, is exempt from the
bond requirement.
3. As changes occur, you are required to provide the department with an update of the list of self insured plans and
trusts for which you act as administrator. You must have a Registration Form completed and attached to your
notification to the Department. (The attached form may be duplicated.) Any change in other information listed
on your application should be promptly reported to the Department.
4. The individual completing the Application on behalf of the third party administrator must sign the Application.
5. Renewal of your Certificate of Registration will be due annually on or before January 1, of each year. The
Renewal Registration of the Plans will be required with the Renewal Application.
6. All service agreements between the third party administrator and the listed plans must be filed with this
registration.
7. All third party administrators are responsible for assuring that the plans they administer are themselves duly
registered.
Rev. 5/20
ARKANSAS INSURANCE DEPARTMENT
LICENSE DIVISION
1 COMMERCE WAY, SUITE 104
LITTLE ROCK, AR 72202
PHONE: 501-371-2750
FAX: 501-683-2604
INSTRUCTIONS FOR THIRD PARTY ADMINISTRATOR
APPLICATION FOR REGISTRATION
1. Applicant must complete the Third Party Administrator Application for Registration, Form AID-LI-TPA, and
submit it to the Arkansas Department with a check the amount of $100.00 The check must be made payable to
the “The State Insurance Department Trust Fund.”
2. A $25,000 Surety Bond, executed by an authorized admitted insurer using the bond form, Form AID-LI-
TPABOND, must be attached to the Application for Registration.
Note: Any applicant operating only pursuant to an administrative services agreement, who does not collect,
receive or remit funds on behalf of the Plan(s), is exempt from the bond requirement. Any applicant performing
services only on behalf of single employer self-funded plans or collectively bargained plans, is exempt from the
bond requirement.
3. As changes occur, you are required to provide the department with an update of the list of self insured plans and
trusts for which you act as administrator. You must have a Registration Form completed and attached to your
notification to the Department. (The attached form may be duplicated.) Any change in other information listed
on your application should be promptly reported to the Department.
4. The individual completing the Application on behalf of the third party administrator must sign the Application.
5. Renewal of your Certificate of Registration will be due annually on or before January 1, of each year. The
Renewal Registration of the Plans will be required with the Renewal Application.
6. All service agreements between the third party administrator and the listed plans must be filed with this
registration.
7. All third party administrators are responsible for assuring that the plans they administer are themselves duly
registered.
FORM AID-LI-TPA (5/20)
ARKANSAS INSURANCE DEPARTMENT
LICENSE DIVISION
1 COMMERCE WAY, SUITE 104
LITTLE ROCK, AR 72202
PHONE: 501-371-2750
FAX: 501-683-2604
THIRD PARTY ADMINISTRATOR
APPLICATION FOR REGISTRATION
1. TPA NAME: ______________________________________________________________________________
2. TPA FEDERAL TAX ID #: _____________________________________________
3. MAILING ADDRESS:_______________________________________________________________________
Street and Number or P.O. Box
City
State
Zip
4. PHYSICAL ADDRESS: _____________________________________________________________________
Street and Number
City
State
Zip
5. NAME OF CONTACT PERSON ______________________________________________________________
6. PHONE NUMBER OF CONTACT PERSON: ____________________________________________________
7. FAX NUMBER OF TPA: ____________________________________________________________________
8. TPA IS A:
CORPORATION
PARTNERSHIP
SOLE PROPRIETORSHIP
LLP
LLC
9. DOES THE TPA USE AN AGENT FOR SERVICE:
YES
NO
IF YES, PLEASE LIST NAME, ADDRESS AND PHONE NUMBER OF AGENT FOR SERVICE:
NAME_______________________________________________ PHONE NUMBER____________________
ADDRESS: _______________________________________________________________________________
Street and Number or P.O. Box
City
State
Zip
10. BOND INFORMATION (IF BOND IS REQUIRED OF TPA)
BOND NUMBER __________________________ DATE BOND ISSUED ____________________________
NAME OF ISSUING COMPANY _____________________________________________________________
11. LIST ALL EMPLOYEE WELFARE BENEFIT PLANS FOR WHICH YOU ACT AS THIRD PARTY
ADMINISTRATOR. ATTACH A LIST OF ANY ADDITIONAL PLANS AS NECESSARY. TYPES
OF PLANS THAT MUST BE LISTED ARE:
SELF-FUNDED SINGLE EMPLOYER PLANS,
COLLECTIVELY BARGAINED WELFARE BENEFIT PLANS (TAFT-HARTLEY TRUST),
MULTIPLE EMPLOYER TRUSTS,
FULLY INSURED MULTIPLE EMPLOYER WELFARE ASSOCIATIONS, AND
NOT-FULLY INSURED WELFARE ASSOCIATIONS.
ALL OF THE ABOVE PLANS MUST HAVE A FORM AID-LI-SELF (1-05) COMPLETED AND SENT
TO THE ARKANSAS INSURANCE DEPARTMENT.
Name of Employer
Federal Tax ID Number
Type of Plan
Do you process funds?
(Yes or No)
__________________________________________________________________________________________
__________________________________________________________________________________________
FORM AID-LI-TPA (5/20) Page 2
Name of Employer
Federal Tax ID Number
Type of Plan
Do you process funds?
(Yes or No)
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
AFFIDAVIT
I, the undersigned, do hereby swear or affirm under oath that the information submitted above is true and
accurate to the best of my knowledge and belief.
Name and Title _______________________________________________________Date _________________
State of __________________________
County of ________________________
Subscribed to and sworn or affirmed before me on this ______ Day of ________________________, 20____.
My Commission Expires: _________________
Seal
_________________________________________________
Notary Public
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