Application For Certificate Of Authority Form. This is a New Hampshire form and can be use in Third Party Administrator Workers Comp.
Tags: Application For Certificate Of Authority, New Hampshire Workers Comp, Third Party Administrator
State of New Hampshire George N. Copadis Labor Commissioner David M. Wihby Deputy Labor Commissioner Department of Labor State Office Park South 95 Pleasant Street Concord, NH 03301 603/271-3176 TDD Access: Relay NH 1-800-735-2964 FAX: 603/271-6149 APPLICATION for CERTIFICATE of AUTHORITY THIRD PARTY ADMINISTRATORS CHAPTER 161 ADMINISTRATOR NAME: ______________________________________________________________ TRADE NAME (if any) __________________________________________________________________ DOMICILE: ___________________________________________________________________________ ADDRESS: ____________________________________________________________________________ ______________________________________________________________________________________ CONTACT NAME: _____________________________________________________________________ CONTACT TITLE: ______________________________________________________________________ PHONE: ____________________________________ FEIN # ___________________________________ CONTACT ADDRESS_____________________________________________________________________________ Note: This department will only correspond with the named contact person. This individual may be in the company or a contracted person such as a consultant. Fees Application Examination $200.00 Annual Renewal $100.00 (Due 60 days prior to license expiration) All checks must be made payable to: New Hampshire Labor Department. Our review process will not being until fees are paid. New Hampshire law does not allow for the payment of fees after the issuance of the license. American LegalNet, Inc. www.USCourtForms.com SECTION 1 – MANAGEMENT 1.) OFFICIAL LIST OF ALL INDIVIDUALS responsible for the conduct of affairs of the administrator. The list should give the name, position occupied, address and the professional qualifications of each of these individuals. It should also be sworn to as a true and complete list by the secretary of the administrator. The list shall include: · · · · · · Board of Directors Board of Trustees Executive Committee/Governing Board/Committee Principal Officers Shareholders (10% or more) Others exercising control/influence SECTION 2 – FINANCIAL · A Security Deposit Agreement from a New Hampshire bank indicating that a minimum of $100,000 has been placed with that bank and pledged to the Commissioner of Labor of the State of New Hampshire, or · Fidelity bond with a minimum face value of 1 million dollars, or · A surety bond issued for a minimum of $100,000 by a surety company licensed to do business in the State of New Hampshire. 1.) THE PHYSICAL ADDRESS WHERE THE BOOKS AND RECORDS MAINTAINED BY THE ADMINISTRATOR ARE LOCATED: 2.) THE FOLLOWING DOCUMENTS MUST BE INCLUDED WITH THE APPLICATION: · · Federal Tax Returns (last 3 years) Audited Financial statement (2 most recent years) SECTION 3 – DOCUMENTARY 1.) CERTIFIED COPIES OF ALL BASIC ORGANIZATIONAL DOCUMENTS, including Articles of Incorporation, Articles of Association, partnership agreements, trade name certificate, trust agreement, shareholder agreement, recent certificate of good standing for state of domicile and for State of New Hampshire and all amendments thereto. These items should be certified by the proper domiciliary state of official. 2.) COPY OF THE BY-LAWS of the applicant certified as a true and correct copy of the secretary of the company. American LegalNet, Inc. www.USCourtForms.com 2 3.) BUSINESS PLAN STATEMENT. Attach a separate sheet outlining the administrator’s Business Plan, including staffing levels proposed for New Hampshire and nationwide. 4.) SUMMARY of INSURANCE POLICIES. Attach copies of binder pages from insurance carriers for Administrator’s: “Errors & Omissions” Insurance (carrier/limits/policy period) “Directors & Officers” Insurance (carrier/limits/policy period) Any other pertinent coverage’s (carrier/limits/policy period) (12/15/95) American LegalNet, Inc. www.USCourtForms.com 3