"Third Party Administrator Change Form" - Montana

Third Party Administrator Change Form is a legal document that was released by the Montana Department of Labor and Industry - a government authority operating within Montana.

Form Details:

  • The latest edition currently provided by the Montana Department of Labor and Industry;
  • Ready to use and print;
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  • Fill out the form in our online filing application.

Download a fillable version of the form by clicking the link below or browse more documents and templates provided by the Montana Department of Labor and Industry.

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THIRD PARTY ADMINISTRATOR
CHANGE FORM
AN ADJUSTER OR THIRD PARTY ADMINISTRATOR HAS CHANGED
Please complete all that apply:
The following claims are assumed by the new TPA:
Past
Present
Future
List other information needed to identify claims assumed:
Effective Date:
Contact Person
Phone Number:
E-Mail:
Please check one:
The Primary Adjuster for the Insurer has changed
Insurer’s Name:
FEIN:
Previous Adjuster:
New Adjuster:
FEIN:
New Adjuster City/State:
Phone Number:
E-Mail:
The Employer’s Primary Adjuster (Exception Adjuster) has changed
Employer’s Name:
FEIN:
Insurer’s Name(s): (list all)
FEIN:
(Use another page if necessary)
Previous Adjuster:
New Adjuster:
FEIN:
New Adjuster City/State:
Phone Number:
E-mail:
Date:
Signed: ____________________________
Printed Name & Title:
Please PRINT and Sign.
Mail to:
Mike Bartow, DMU
Employment Relations Division
PO Box 8011
Helena, MT 59604-8011
Fax to:
(406) 444-4140
Email to:
mbartow@mt.gov
If you have numerous changes, an alternative format may be accepted. Contact us for details.
ERD-WCCAB/DMU-TPA027 1/2018 dar
THIRD PARTY ADMINISTRATOR
CHANGE FORM
AN ADJUSTER OR THIRD PARTY ADMINISTRATOR HAS CHANGED
Please complete all that apply:
The following claims are assumed by the new TPA:
Past
Present
Future
List other information needed to identify claims assumed:
Effective Date:
Contact Person
Phone Number:
E-Mail:
Please check one:
The Primary Adjuster for the Insurer has changed
Insurer’s Name:
FEIN:
Previous Adjuster:
New Adjuster:
FEIN:
New Adjuster City/State:
Phone Number:
E-Mail:
The Employer’s Primary Adjuster (Exception Adjuster) has changed
Employer’s Name:
FEIN:
Insurer’s Name(s): (list all)
FEIN:
(Use another page if necessary)
Previous Adjuster:
New Adjuster:
FEIN:
New Adjuster City/State:
Phone Number:
E-mail:
Date:
Signed: ____________________________
Printed Name & Title:
Please PRINT and Sign.
Mail to:
Mike Bartow, DMU
Employment Relations Division
PO Box 8011
Helena, MT 59604-8011
Fax to:
(406) 444-4140
Email to:
mbartow@mt.gov
If you have numerous changes, an alternative format may be accepted. Contact us for details.
ERD-WCCAB/DMU-TPA027 1/2018 dar