Form TPA Rev. 8/01/2006 Ark. C ode Ann. 11-9-302 (b) and AWC C Rule 099.38 ARKANSAS WORKERS' COMPENSATION COMMISSION TPA ADMINISTRATION 324 Spring Street, Little Rock, AR 72201 Mail: P. O. Box 950, Little Rock, AR 72203-0950 501-682-2783 / 1-800-622-4472 TPA Date_______________________ THIRD PARTY ADMINISTRATOR Application / Registration Form 1. 2. 3. 4. 5. 6. 7. Applicant (legal) name: ____________________________________________________________________________ Federal Employer Identification Number (FEIN): _______________________________________________________ Applicant trade name / DBA name: __________________________________________________________________ Applicant home office address: _____________________________________________________________________ Applicant main phone # ___________________________________ Applicant toll free # ________________________ Applicant is: G Corporation, G Partnership, G Individual, G Other (specify) ________________________________ Indicate the desired effective date for Third Party Administrator approval: _____________________________________ Complete items 8 through 11 for the person who will serve as the company's Administrator (home office contact) to the Commission regarding renewing the TPA authority and compliance with Commission Rule 099.38. 8. 9. Administrator's name: _____________________________________________________________________________ Administrator's E-mail address: _____________________________________________________________________ 10. Administrator's mailing address: ___________________________________________________________________ 11. Administrator's direct phone #: _______________________________ Fax #: ________________________________ 12. Complete the following for each location that will be handling Arkansas workers' compensation claims. If the Administrator (above) will also be a claims location contact, please repeat the above information in the blanks below. Please complete the same information for each additional location handling Arkansas claims. If there are more than five (5) locations at which claims will be handled, please copy page 2 and include the additional page(s) with the application. Location Name: ____________________________________________________________________________ Claim Manager: ____________________________________________________________________________ Claim Manager E-mail address________________________________________________________________ Claim Manager Direct Phone ________________________ Claim Manager Fax ________________________ Location Mailing Address: _____________________________________________________________________ Location City: ______________________________ Location State: ______ Location Zip: ______________ Page 1 of 3 Form TPA (Eff 8/01/06) American LegalNet, Inc. www.FormsWorkflow.com Location Name: ____________________________________________________________________________ Claim Manager: ____________________________________________________________________________ Claim Manager E-mail address________________________________________________________________ Claim Manager Direct Phone ________________________ Claim Manager Fax ________________________ Location Mailing Address: _____________________________________________________________________ Location City: ______________________________ Location State: ______ Location Zip: ______________ Location Name: ____________________________________________________________________________ Claim Manager: ____________________________________________________________________________ Claim Manager E-mail address________________________________________________________________ Claim Manager Direct Phone ________________________ Claim Manager Fax ________________________ Location Mailing Address: _____________________________________________________________________ Location City: ______________________________ Location State: ______ Location Zip: ______________ Location Name: ____________________________________________________________________________ Claim Manager: ____________________________________________________________________________ Claim Manager E-mail address________________________________________________________________ Claim Manager Direct Phone ________________________ Claim Manager Fax ________________________ Location Mailing Address: _____________________________________________________________________ Location City: ______________________________ Location State: ______ Location Zip: ______________ Location Name: ____________________________________________________________________________ Claim Manager: ____________________________________________________________________________ Claim Manager E-mail address________________________________________________________________ Claim Manager Direct Phone ________________________ Claim Manager Fax ________________________ Location Mailing Address: _____________________________________________________________________ Location City: ______________________________ Location State: ______ Location Zip: ______________ Page 2 of 3 Form TPA (Eff 8/01/06) American LegalNet, Inc. www.FormsWorkflow.com This application is to be completed and sent with the application fee of one hundred dollars ($100) payable to the Arkansas Workers' Compensation Commission, P. O. Box 950, Little Rock, AR 72203-0950. I certify that the information submitted with this application is true and correct to the best of my knowledge. Further, I agree to update any change in locations, location personnel or report any data material to this application to the Commission as the need may arise. _____________________________________________________________ Legal Name of Applicant _____________________________________________________________ Name(Print) of authorized Official of Applicant _____________________________________________________________ Title of Official _____________________________________________________________ Signature of Official ______________________________________________________________ Date State of ______________________ County of ______________________A Subscribed and sworn to before me by _________________________________________________________________ on this __________ day of ______________________, 2 ______. (Seal) _____________________________________ Notary Public My commission expires: _________________________________. Page 3 of 3 Form TPA (Eff 8/01/06) American LegalNet,