Form HSMV77067 "Application for Authority to Conduct Class E Third Party Administrator (Tpa) Driver License Exams" - Florida

What Is Form HSMV77067?

This is a legal form that was released by the Florida Department of Highway Safety and Motor Vehicles - a government authority operating within Florida. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on June 1, 2017;
  • The latest edition provided by the Florida Department of Highway Safety and Motor Vehicles;
  • 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 printable version of Form HSMV77067 by clicking the link below or browse more documents and templates provided by the Florida Department of Highway Safety and Motor Vehicles.

ADVERTISEMENT
ADVERTISEMENT

Download Form HSMV77067 "Application for Authority to Conduct Class E Third Party Administrator (Tpa) Driver License Exams" - Florida

117 times
Rate (4.8 / 5) 6 votes
DIVISION OF MOTORIST SERVICES
BUREAU OF MOTORIST COMPLIANCE
APPLICATION FOR AUTHORITY TO CONDUCT
CLASS E THIRD PARTY ADMINISTRATOR (TPA) DRIVER LICENSE EXAMS
This Application is to be used by businesses that want to receive Department approval to conduct Class E Third
Party Administrator (TPA) Driver License Exams. Individuals, associations, corporations or partnerships are eligible
to apply in accordance with the provisions of Section 322.56, Florida Statutes.
This Application and all required documentation must be submitted to:
Department of Highway Safety and Motor Vehicles
Bureau of Motorist Compliance
Class E Third Party Administrator Program
2900 Apalachee Parkway, Room A201 MS 97
Tallahassee, Florida 32399-0570
This Application must be completed in full with all required documents attached at the time the Application is
submitted to the Department for consideration.
If approved, the Class E Exam authorization is valid for a three (3) year period. A new Application with supporting
documentation is required after the three year period ends if you would like to continue to administer Class E
Exams.
Please indicate which service(s) the business is applying for:
 Class E General Knowledge – Classroom Setting
In Person Proctored Exam at Third Party’s Place of Business
 Class E General Knowledge – Online
Exams Taken by Applicants via the Internet Using the Business’ Website
 Class E Driving Skills
In Person Driving Skills Exam Conducted via a Tablet Computer (if approved, a tablet and
successful completion of Class E Driving Skills Exam Training are required)
Page 1
HSMV 77067 (1/14) [REVISED 6/2017)
DIVISION OF MOTORIST SERVICES
BUREAU OF MOTORIST COMPLIANCE
APPLICATION FOR AUTHORITY TO CONDUCT
CLASS E THIRD PARTY ADMINISTRATOR (TPA) DRIVER LICENSE EXAMS
This Application is to be used by businesses that want to receive Department approval to conduct Class E Third
Party Administrator (TPA) Driver License Exams. Individuals, associations, corporations or partnerships are eligible
to apply in accordance with the provisions of Section 322.56, Florida Statutes.
This Application and all required documentation must be submitted to:
Department of Highway Safety and Motor Vehicles
Bureau of Motorist Compliance
Class E Third Party Administrator Program
2900 Apalachee Parkway, Room A201 MS 97
Tallahassee, Florida 32399-0570
This Application must be completed in full with all required documents attached at the time the Application is
submitted to the Department for consideration.
If approved, the Class E Exam authorization is valid for a three (3) year period. A new Application with supporting
documentation is required after the three year period ends if you would like to continue to administer Class E
Exams.
Please indicate which service(s) the business is applying for:
 Class E General Knowledge – Classroom Setting
In Person Proctored Exam at Third Party’s Place of Business
 Class E General Knowledge – Online
Exams Taken by Applicants via the Internet Using the Business’ Website
 Class E Driving Skills
In Person Driving Skills Exam Conducted via a Tablet Computer (if approved, a tablet and
successful completion of Class E Driving Skills Exam Training are required)
Page 1
HSMV 77067 (1/14) [REVISED 6/2017)
I. GENERAL INFORMATION (all fields must be legible and completed in full):
_______________________________________________________________________________
Name of Business (or, if applicable, Parent Company if business is a “d/b/a”):
_______________________________________________________________________________
Name of Subsidiary (or, if applicable, “d/b/a” if there is a Parent Company):
_______________________________________________________________________________
Business - Physical Florida Address
City
State
Zip
____________________________________ ________________________________________
Business Phone Number
Business Fax Number
_______________________________________________________________________________
Business Email Address
____________________________________ ________________________________________
Contract Manager
Contract Manager’s Phone Number
________________________________________________________________________________
Contract Manager’s Email Address
This Application, the Contract for Services and all backup documentation are required to be submitted with the
third party’s business name listed exactly as it is listed on the business’ Certificate of Fictitious Name or Certificate
of Incorporation from the Department of State as proof of an active registered business in the State of Florida, as
specified in the Class E Third Party Administrator Contract.
Any modifications to the business name will require submission of a new Application.
If there is more than one business location, attach a separate document to this application and please provide the
full address and phone number for all business locations where the examination services will be conducted and list
what type of exam services will be conducted at each location. All business locations must meet all Class E Third
Party Administrator Contract requirements.
The Department requires a 30 day notification from the Third Party Administrator prior to the Third Party
Administrator securing additional business locations, as outlined in the Contract.
Page 2
HSMV 77067 (1/14) [REVISED 6/2017)
II. OWNER(S)/PARTNER(S)/CORPORATE OFFICER(S):
List the name(s), addresses and positions of the owners and/or partners and/or corporate officers in the table
below. Any change in ownership requires submission of a new Application.
Ownership
Full Name
Address
Position/Title
Percentage
III. BUSINESS MODEL SUMMARY:
A.
In an attached document entitled “Business Model Summary” please describe in detail how the business
plans to deliver driver license exam services. Any change in the business model requires submission of a new
Application.
B.
If you are administering driving skill exams and will be using business vehicles or personal vehicles, enter
the vehicle information requested below for every vehicle that will be used. Attach a current Certificate of
Insurance for each vehicle listed. Whenever motor vehicles are replaced or added, notify the Department and
forward a valid certificate of insurance for the new or replacement vehicle(s).
Make
Model
Year
VIN
IV. SUPPLEMENTARY INFORMATION
A.
The Third Party Administrator, each examiner, employee, agent, corporate officer, partner, and owner
must submit to a fingerprint-based background check performed by a “Live Scan” Provider with results provided to
the Department at the time of the Application. The Department will notify the Third Party Administrator of any
disqualifying background check.
1.
The Third Party Administrator must notify the Department’s Contract Manager in writing of the
intent to hire new employees or the intent to add or replace corporate officers, partners or owners at least fifteen
(15) days prior to the individual beginning employment or having any association with the Third Party
Administrator.
2.
Each new employee hired by the Third Party Administrator, each new corporate officer, partner
or owner must submit to a fingerprint-based background check performed by a “Live Scan” Provider before
beginning employment or having any association with the Third Party Administrator.
Page 3
HSMV 77067 (1/14) [REVISED 6/2017)
B.
Each of the Third Party Administrator’s examiners, employees, agents, corporate officers, partners and
owners must submit to a complete history driver license record check by the Department at the time of
Application. The Department will notify the Third Party Administrator of any disqualifying driver license reviews.
Please provide the information requested for each examiner, employee, agent, corporate officer, partner and
owner.
Date FDLE
Date of
LiveScan
Full Name
Driver License Number
State Issued
Birth
Fingerprinting
Conducted
With regard to driver license qualifications, all employees must possess a valid Class E Driver License or its
equivalent with no cancellations, suspensions or revocations for a minimum of three (3) years prior to and for the
duration of the Contract for Class E Examination Services. The driving record must contain no more than three
chargeable motor vehicle crashes or violations as defined in Chapter 316, Florida Statutes, during any consecutive
three year period during the term of the Contract for Class E Examination Services.
With regard to FDLE fingerprint-based background checks, no employees shall have any criminal charges or
convictions for offenses bearing on his or her ability to fill a position of trust, including, but not limited to, alcohol
or drug-related offenses within ten years prior to the date of submission of this Application; any misdemeanor
involving dishonesty or false statement at any time; or any felony at any time. The Department has the authority
to deny an Application as a result of these charges or convictions, regardless of adjudication.
I hereby certify that the information supplied above is true, accurate and complete. I understand that any
fraudulent or misinformation supplied, or information withheld, will result in cancellation of the Contract
between this Third Party Administrator and the Department.
_____________________________________________
Signature
_____________________________________________
Print Name
_____________________________________________
Title
_____________________________________________
Date of Application
Page 4
HSMV 77067 (1/14) [REVISED 6/2017)
THE FOLLOWING ITEMS ARE REQUIRED BEFORE A CONTRACT CAN BE EXECUTED:
1.
Business Model Summary: Describe in detail how the business plans to deliver driver license exam
services.
2.
Department of State Proof of Active Business Status: A current copy of the Certificate of Fictitious Name
or Certificate of Incorporation from the Department of State as specified in the Third Party Administrator Contract.
3.
Commercial General Liability Insurance: A Certificate of Commercial General Liability Insurance as
described in the Third Party Administrator Contract. Required policy liability limits are $1,000,000 for each
occurrence, and $2,000,000 per aggregate. The certificate must state that a thirty (30) day notice will be given to
the Bureau of Motorist Compliance, Department of Highway Safety and Motor Vehicles in the event of cancellation
of the policy. The insurance must also include a Hold Harmless Contract in favor of the State of Florida,
Department of Highway Safety and Motor Vehicles, must name the Department as the certificate holder, and
must include the State of Florida as an Additional Insured for the entire length of the Contract.
4.
Automobile Liability Insurance (if applicable): For Class E Driving Skills Exam Third Party Administrators
only, proof of Automobile Liability Insurance, if using business vehicles, is required. Required automobile policy
liability limits are $10,000 PIP, $20,000 PDL and $10,000 BIL. The insurance certificate must include a description of
the motor vehicles utilized in the administration of the driving skills exam and must state that a thirty (30) day
notice will be given to the Bureau of Motorist Compliance, Department of Highway Safety and Motor Vehicles in
the event of cancellation of the policy.
5.
Workers’ Compensation Insurance: A Certificate of Workers’ Compensation Insurance as described in the
Third Party Administrator Contract is required with a $100,000 liability limit for each accident, $500,000 policy
limit, and $100,000 for each employee. Workers’ Compensation Exemption Certifications can be accepted in lieu of
the required policy limits; however, exemptions will only be accepted for companies with a single owner - sole
proprietorship.
6.
$200,000 Performance Bond: A $200,000 Performance Bond is required in the Third Party Administrator
Contract. Note: if sending in an application to conduct more than a single service, a $200,000 Performance Bond is
required for each service ($200,000 Performance Bond for Class E Knowledge Examination Services; $200,000
Performance Bond for Class E Driving Skills Examination Services).
7.
Class E Knowledge Contract / Class E Driving Skills Contract: An original, completed in full and signed
Third Party Administrator Contract for the service(s) you are submitting the Application to conduct (Class E
Knowledge Examination Services and/or Class E Driving Skills Examination Services).
Hold Harmless Endorsement: The Hold Harmless Endorsement should be submitted on company
8.
letterhead, signed and dated by a Corporate Officer, with the following language: “[your company name (in full)
here] indemnifies and holds harmless the State of Florida, Department of Highway Safety and Motor Vehicles, and
department employees from and against all losses, claims, demands, payments, suits, actions, recoveries and
judgments of every nature and description brought or recoverable against it or them by reason of any act or
omission of the Third Party Administrator or the Third Party Administrator’s agents, examiners, or other employees
in execution of the work or in consequence of any negligence or carelessness in guarding the same.”
Page 5
HSMV 77067 (1/14) [REVISED 6/2017)
Page of 5