Form SI TPA Page 1 of 2 Rev. 0 1915 NORTH STILES AVENUE OKLAHOMA CITY, OK 73105 (405)522 - 3222 or In - State Toll Free (8 55 ) 291 - 3612 APPLICATION FOR THIRD PARTY ADMINISTRATOR PERMIT Date The undersigned, a company providing Third - Party Administrative Services to Own Risk employers and/or Gr oup Self - Insurance Associations , hereby applies for permission to act as a n approved Third - Party Administrator . To enable the Workers' Compensation Commission to determin e the applicant provide these services, sa id applicant hereby states the following: 1. TPA Name 2. Desired effective date (application should be submit ted 3 0 days in advance) 3. TPA # (if a renewal applicant) 4. Name of Parent Company, if applicable 5. Primary contact for TPA (Whom we should contact for additional information about this application) Name Title Email address Telephone Number 6. Home office a ddress , phone number & e - mail address 7. Oklahoma office address, phone number & e - mail address 8. Years in business: Nationally In Oklahoma 9 . Please include the following items with the application : a. A nonrefundable $1,000 application b. A udited financial statements for the most recent fiscal year , including a balance sheet, statement of income, statement of cash flows, and notes . c. A list of all claims adjus ters on staff. Please include the OK license number for each adjuster; it is not necessary to submit copies of each license . d. A list of all claims managers or equivalent supervisory personnel. Please include a brief resume for each manager. e. A description of how service fees are determined. f. Services performed by the applicant. If services are provided other than claims adjusting, such as safety consulting, marketing or accounting functions, please pr ovide a brief resume of the principal employee(s) providing these services. g. A description of how client funds are handled for payment of claims. American LegalNet, Inc. www.FormsWorkFlow.com Form SI TPA Page 2 of 2 Rev. 0 j . k . A list of all Own Risk employers, Group Self Insurance associations, and other companies the applicant provides services for. l . or the declarations page, showing the coverage amounts and limits. The p remium amount may be redacted. m. Fidelity Bond or Crime policy , or the declarations page, showing the coverage amounts and limits. The premium amount may be redacted. 10 . In consideration of the approval of this application, the applicant her eby : a. E Commission ; and b. Certifies that the TPA: 1) Has adequate personnel on staff to handle t he volume and type of work; 2) Establishes claims at the most likely outcom e, rather than best case; 3) Retains independence when setting claim reserves; and 4) Maintains adequate computerized records and paper claims files on each claim. false statement or representation, who willfully and knowingly omits or conceals any material information, or who employs any device, scheme, or artifice, or who aids and abets any person for the purpose of: (1) obtaining imprisonment, a fine or both. I declare under penalty of perjury that I have examined this application and all statements contained herein, and to the best of my knowledge and belief, they are true, correct and complete. Signed this day of , 20. Signature of Authorized Representative (Note: Person signing should have authority to bind the applicant to the agreements contained herein) Print Name of Authorized Representative Title of Authorized Representative Mailing Address City State Zip Code Street Address, if different from Mailing Address City State Zip Code E-mail Address of Authorized Representative Telephone Number of Authorized Representative Send applicaaddress at the top of page one. Alternatively, all items may be emailed to @.ok.gov. American LegalNet, Inc. www.FormsWorkFlow.com