Form FIS0865 "Third Party Administrator Jurat Page for Annual Renewal" - Michigan

What Is Form FIS0865?

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

Form Details:

  • Released on May 1, 2015;
  • The latest edition provided by the Michigan Department of Insurance and Financial Services;
  • 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 FIS0865 by clicking the link below or browse more documents and templates provided by the Michigan Department of Insurance and Financial Services.

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Download Form FIS0865 "Third Party Administrator Jurat Page for Annual Renewal" - Michigan

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FIS 0865 (5/15) Department of Insurance and Financial Services Page 1 of 1
This symbol indicates that additional
Third Party Administrator (TPA)
documentation may be required.
On each attachment, enter name of TPA and
Jurat Page for Annual Renewal
Tax ID number (FEIN) in upper right corner.
Name of Third Party Administrator (TPA)
TPA Tax ID number (FEIN)
TPA Mailing Address Line 1
Address has not changed
TPA Primary Office Address Line 1
Address has not changed
(can be a PO Box)
since last update or renewal
(must be a street address)
since last update or renewal
Mailing Address Line 2
Primary Office Address Line 2, including floor or suite number
City
State
ZIP Code
City
State
ZIP Code
Complete contact and organizational information below only if it has changed since the last update or renewal:
TPA Main Telephone number
TPA Main Fax number
Website address (if applicable)
Name and Title of General Contact Person
Email Address of General Contact Person
Telephone number
Check box if state of domicile has not
TPA is organized as the following type of business:
OR
TPA State of Domicile
changed since last update or renewal
(check only if there was a change since the last update or renewal)
Michigan
If state of domicile changed since last update
Corporation
Partnership
Sole Proprietorship
or renewal, attach new FIS 0860 Third Party
Other
Administrator Consent to Service form
Limited Liability Corporation (LLC)
Limited Liability Partnership (LLP)
List any change to trade name you currently do or intend to do business under in Michigan.
As indicated below, attach appropriate documentation; attachments should be
copies of documents that were certified by state of domicile.
If incorporated, copy of certified Articles of Incorporation
If any change to a trade name is listed above, attach copy of Assumed Name or
If not incorporated, copy of certified Articles of Organization, Partnership
dba filing.
Agreement, business license filing, etc.
Attach a list of each of the following in relation to the TPA, even if there were no changes since your last update or renewal:
Please attach a list as shown in the format below. List should include all of the following
ALL officers of the corporation, partners,
ALL stockholders
ALL members of the Board of Directors of the corporation including Board of
or sole proprietor
of 10% or more
Trustees, Executive Committee, and any other governing body
Notify DIFS of any changes to the list within 30 days of such a change; indicate revisions since the previous notification with an asterisk (*). Attach an FIS 0862 Third Party
Administrator Affiliation Statement for each addition to the list. Retain the updated list. It will be necessary to complete future TPA renewals.
Name
Title or relationship to the TPA
List should be prepared
using your office
information system in
the format shown here:
Each person and each corporate stockholder of 10% or more added since your last update or renewal report must complete an FIS 0862 Third Party Administrator
Affiliation Statement. All FIS 0862 forms must be attached to the FIS 0865 Third Party Administrator Jurat Page for Annual Renewal.
Submit a completed FIS 0850 Third Party Administrator Financial Statement with the completed FIS 0865 Third Party Administrator Jurat Page for Annual Renewal.
PA 218 of 1984 as amended requires submission and verification by Third Party Administrators requesting a renewal of their Michigan Certificate of Authority. Failure to properly complete this form or properly advise
DIFS of changes in information given may result in denial or revocation of Certificate of Authority or other compliance action
FIS 0865 (5/15) Department of Insurance and Financial Services Page 1 of 1
This symbol indicates that additional
Third Party Administrator (TPA)
documentation may be required.
On each attachment, enter name of TPA and
Jurat Page for Annual Renewal
Tax ID number (FEIN) in upper right corner.
Name of Third Party Administrator (TPA)
TPA Tax ID number (FEIN)
TPA Mailing Address Line 1
Address has not changed
TPA Primary Office Address Line 1
Address has not changed
(can be a PO Box)
since last update or renewal
(must be a street address)
since last update or renewal
Mailing Address Line 2
Primary Office Address Line 2, including floor or suite number
City
State
ZIP Code
City
State
ZIP Code
Complete contact and organizational information below only if it has changed since the last update or renewal:
TPA Main Telephone number
TPA Main Fax number
Website address (if applicable)
Name and Title of General Contact Person
Email Address of General Contact Person
Telephone number
Check box if state of domicile has not
TPA is organized as the following type of business:
OR
TPA State of Domicile
changed since last update or renewal
(check only if there was a change since the last update or renewal)
Michigan
If state of domicile changed since last update
Corporation
Partnership
Sole Proprietorship
or renewal, attach new FIS 0860 Third Party
Other
Administrator Consent to Service form
Limited Liability Corporation (LLC)
Limited Liability Partnership (LLP)
List any change to trade name you currently do or intend to do business under in Michigan.
As indicated below, attach appropriate documentation; attachments should be
copies of documents that were certified by state of domicile.
If incorporated, copy of certified Articles of Incorporation
If any change to a trade name is listed above, attach copy of Assumed Name or
If not incorporated, copy of certified Articles of Organization, Partnership
dba filing.
Agreement, business license filing, etc.
Attach a list of each of the following in relation to the TPA, even if there were no changes since your last update or renewal:
Please attach a list as shown in the format below. List should include all of the following
ALL officers of the corporation, partners,
ALL stockholders
ALL members of the Board of Directors of the corporation including Board of
or sole proprietor
of 10% or more
Trustees, Executive Committee, and any other governing body
Notify DIFS of any changes to the list within 30 days of such a change; indicate revisions since the previous notification with an asterisk (*). Attach an FIS 0862 Third Party
Administrator Affiliation Statement for each addition to the list. Retain the updated list. It will be necessary to complete future TPA renewals.
Name
Title or relationship to the TPA
List should be prepared
using your office
information system in
the format shown here:
Each person and each corporate stockholder of 10% or more added since your last update or renewal report must complete an FIS 0862 Third Party Administrator
Affiliation Statement. All FIS 0862 forms must be attached to the FIS 0865 Third Party Administrator Jurat Page for Annual Renewal.
Submit a completed FIS 0850 Third Party Administrator Financial Statement with the completed FIS 0865 Third Party Administrator Jurat Page for Annual Renewal.
PA 218 of 1984 as amended requires submission and verification by Third Party Administrators requesting a renewal of their Michigan Certificate of Authority. Failure to properly complete this form or properly advise
DIFS of changes in information given may result in denial or revocation of Certificate of Authority or other compliance action