COMMISSIONER OF INSURANCE ·INDUSTRIAL LOAN COMMISSIONER·SAFETY FIRE COMMISSIONER OFFICE OF COMMISSIONER OF INSURANCE Ralph T. Hudgens, Commissioner 2 Martin Luther King Jr., Dr., Suite 604, West Tower, Atlanta, GA 30334 www.oci.ga.gov Phone: 404-656-7556 Fax: 770-344-5798 Email: TBrewster@oci.ga.gov THIRD PARTY ADMINISTRATOR NOTICE OF EXEMPTION GID-242-NT JAN2013 NON-TRADITIONAL 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: _________________________________________________________________________________ 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: _____________________________________________ Sworn to and Subscribed before Me Signature: _____________________________________________ this ________ day of ________________, _______. Print Name: ___________________________________________ _________________________________________ (Notary Public) Print Title: ___________________________________________ (SEAL) This office does not discriminate in employment, programs or services. Disabled persons can contact 404-656-2056 to obtain this document in another format. Page 1 of 1 American LegalNet, Inc. www.FormsWorkFlow.com www.oci.ga.gov OFFICE OF COMMISSIONER OF INSURANCE THIRD PARTY ADMINISTRATOR NOTICE OF EXEMPTION GID-242-NT JAN2013 NON-TRADITIONAL § 33-23-100. (Effective January 1, 2013. See note.) Definitions; exemptions; applicability of Code Sections 33-24-59.5 and 33-24-59.14 (a) As used in this article, the term: (1) "Administrator" means any business entity that, directly or indirectly, collects charges, fees, or premiums; adjusts or settles claims, including investigating or examining claims or receiving, disbursing, handling, or otherwise being responsible for claim funds; or 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 that act on behalf of a single or multiple employer self-insurance health plan or a self-insured municipality or other political subdivision. 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. For purposes of this article, each activity undertaken by the administrator on behalf of an insurer or the client of the administrator is considered a transaction and is subject to the provisions of this title. (2) "Business entity" means a corporation, association, partnership, sole proprietorship, limited liability company, limited liability partnership, or other legal entity. (3) "Standard financial quarter" means a three-month period ending on March 31, June 30, September 30, or December 31 of any calendar year. (b) Notwithstanding the provisions of subsection (a) of this Code section, the following are exempt from licensure so long as such entities are acting directly through their officers and employees: (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 nonaffiliate 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; This office does not discriminate in employment, programs or services. Disabled persons can contact 404-656-2056 to obtain this document in another format. Page 2 of 3 American LegalNet, Inc. www.FormsWorkFlow.com www.oci.ga.gov OFFICE OF COMMISSIONER OF INSURANCE THIRD PARTY ADMINISTRATOR NOTICE OF EXEMPTION GID-242-NT JAN2013 NON-TRADITIONAL (10) 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 that such company does not adjust or settle claims; (11) A person who adjusts or settles claims in the normal course of his or her practice or employment as an attorney and who does not collect charges or premiums in connection with life or accident and sickness insurance coverage or annuities; (12) An insurance company licensed in this state or its affiliate if such insurance company or its affiliate is solely administering limited benefit insurance. For the purpose of this paragraph, the term "limited benefit insurance" means accident or sickness insurance designed, advertised, and marketed to supplement major medical insurance and specifically shall include accident only, CHAMPUS supplement, disability income, fixed indemnity, long-term care, or specified disease insurance; or (13) An association that administers worker