OFFICE OF INSURANCE AND SAFETY FIRE COMMISSIONER COMMISSIONER OF INSURANCE •INDUSTRIAL LOAN COMMISSIONER•SAFETY FIRE COMMISSIONER•COMPTROLLER GENERAL Ralph T. Hudgens, Commissioner 2 Martin Luther King Jr., Dr., Suite 708, West Tower, Atlanta, GA 30334 Phone: 404-656-7556 ◊ Fax: 770-344-5798 ◊ E-mail: TBrewster@oci.ga.gov SPECIAL PROJECTS THIRD PARTY ADMINISTRATOR NOTICE OF EXEMPTION GID-242-EN DECO9 www.oci.ga.gov The following information shall be completed by an officer and provided at the time the exemption is claimed and on an annual basis (12/31) thereafter in accordance with O.C.G.A. §33-23-100 (2)(c). Administrator Name FEIN Street City State Zip Phone Email Reason of Exemption *If claiming exemption due to administration of ERISA plans, please provide a list of the Georgia plans and Federal Tax Identification numbers. Provide copies of all of the Georgia plans administered. ERISA plans Tax Identification # *Please attach additional sheet if unable to fit entire list of applicable ERISA plans Administered. FOLLOWING ATTESTION SHALL BE USED: I do solemnly swear or affirm that I am familiar with the Laws of Georgia relating Administrators; that all the foregoing information and documentary evidence submitted is true, complete and correct to the best of my knowledge and belief. Company Signature Print Name Print Title Sworn to and Subscribed before Me this ______ day of __________________, _______. __________________________________________ (Notary Publicc) (SEAL) This office does not discriminate by race, color, national origin, sex, religion, age or disability in employment, programs or services. Disabled persons needing this document in another format can contact the ADA Coordinator for this office at No. 2 Martin Luther King Jr., Dr., Suite 620, Atlanta, GA 30334 - Phone 404-656-2056. Page 1 American LegalNet, Inc. www.FormsWorkFlow.com OFFICE OF INSURANCE AND SAFETY FIRE COMMISSIONER COMMISSIONER OF INSURANCE •INDUSTRIAL LOAN COMMISSIONER•SAFETY FIRE COMMISSIONER•COMPTROLLER GENERAL Ralph T. Hudgens, Commissioner 2 Martin Luther King Jr., Dr., Suite 708, West Tower, Atlanta, GA 30334 Phone: 404-656-7556 ◊ Fax: 770-344-5798 ◊ E-mail: TBrewster@oci.ga.gov SPECIAL PROJECTS THIRD PARTY ADMINISTRATOR NOTICE OF EXEMPTION GID-242-EN DECO9 www.oci.ga.gov INSTRUCTIONS (To reduce paperwork, please do not submit a copy of this Instructions page with the form.) Per O.C.G.A. § 33-23-100, an administrator is defined as any business entity which, directly or indirectly, collects charges, fees, or premiums from, adjusts or settles claims (including investigating or examining claims, or receiving, disbursing, handling or otherwise being responsible for claim funds), provides underwriting or precertification and preauthorization of hospitalizations or medical treatments, for residents of this state for or on behalf of any insurer, including business entities who act on behalf of multiple employer self-insured health plans, and self-insured municipalities or other political subdivisions. Licensure is also required for administrators who act on behalf of self-insured plans providing workers' compensation benefits pursuant to Chapter 9 of Title 34. As long as the following entities are acting directly through their officers and employees, they are exempt from holding a Third Party Administrator's license: 1. An employer on behalf of its employees or the employees of one or more subsidiary or affiliated corporations of such employer; 2. A union on behalf of its members; 3. An insurance company licensed in this state or its affiliate unless the affiliate administrator is placing business with a non-affiliate insurer not licensed in this state; 4. An insurer which is not authorized to transact insurance in this state if such insurer is administering a policy lawfully issued by it in and pursuant to the laws of a state in which it is authorized to transact insurance; 5. A life or accident and sickness insurance agent or broker licensed in this state whose activities are limited exclusively to the sale of insurance; 6. A creditor on behalf of its debtors with respect to insurance covering a debt between the creditor and its debtors; 7. A trust established in conformity with 29 U.S.C. Section 186 and its trustees, agents, and employees acting thereunder; 8. A trust exempt from taxation under Section 501(a) of the Internal Revenue Code and its trustees and employees acting thereunder or a custodian and its agents and employees acting pursuant to a custodian account which meets the requirements of Section 401(f) of the Internal Revenue Code; 9. A bank, credit union, or other financial institution which is subject to supervision or examination by federal or state banking authorities; 10. 11. 12. 13. A credit card issuing company which advances for and collects premiums or charges from its credit card holders who have authorized it to do so, provided such company does not adjust or settle claims; A person who adjusts or settles claims in the normal course of his or her practice or employment as an attorney (provide a copy of the Georgia Bar Association license) and who does not collect charges or premiums in connection with life or accident and sickness insurance coverage or annuities; A business entity that acts solely as an administrator of one or more bona fide employee benefit plans established by an employer or an employee organization, or both, for whom the insurance laws of this state are preempted pursuant to the federal Employee Retirement Income Security Act of 1974, 29 U.S.C. Section 1001, et seq.*; or An association that administers workers' compensation claims solely on behalf of its members. American LegalNet, Inc. www.FormsWorkFlow.com