The Ohio Ins3213 form is a crucial document for businesses seeking to obtain or renew a Third Party Administrator (TPA) license in Ohio. This form collects essential information about the business entity, including its compliance with state insurance laws and regulations. Completing this form accurately ensures that the entity can operate legally within the state's insurance framework.
The Ohio Ins3213 form is a critical document for business entities seeking to obtain or renew their Third Party Administrator (TPA) license in the state of Ohio. This form is designed to gather comprehensive information about the business entity, including its name, contact details, and licensing history. Applicants must indicate whether they are applying for a resident or non-resident license, and they need to provide their home state and license number if applicable. The form also requires demographic information such as the Federal Employer Identification Number (FEIN) and the National Producer Number (NPN). Additionally, it includes sections for identifying designated licensed producers responsible for compliance with Ohio’s insurance laws. Background questions play a significant role in the application process, asking about any criminal convictions or administrative actions that may affect the entity's eligibility. Furthermore, applicants must confirm that they maintain necessary insurance coverage and adhere to record-keeping requirements. Ultimately, the completion of the Ins3213 form is a vital step for businesses aiming to operate legally and effectively in Ohio's insurance landscape.
Judith L. French, Director
Check appropriate boxes for license requested:
(Please Print or Type)
Resident License
Non-Resident License
Identify Home State:
Identify Home State License #:
Demographic Information
1Business Entity’s Name
2FEIN
3Ohio License Number
4National Producer Number (NPN)
5 Is the business entity affiliated with a financial institution/bank?
Yes
No
6Business Address
7City
8State
9Zip or Foreign Country
10Phone Number (include extension)
11Fax Number
12Business E-Mail Address
13Business Web Site Address
14Mailing Address
15P.O. Box
16City
17State
18Zip or Foreign County
Designated/Responsible Licensed Producer
19Identify at least one Designated/Responsible Licensed Producer responsible for the business entity’s compliance with the insurance laws, rules, and regulations of this state:
Name
SSN
NPN
Background Questions
20
1a. Has the business entity or any owner, partner, officer or director of the business entity, or member or manager of a limited liability company
been convicted of, or is currently charged with, committing a MISDEMEANOR or had a judgment withheld or deferred for a
MISDEMEANOR which has not been previously reported to this insurance department?
You may exclude the following misdemeanor convictions or pending misdemeanor charges: traffic citations, driving under the influence
(DUI), driving while intoxicated (DWI), driving without a license, reckless driving, or driving with a suspended or revoked license.
You may also exclude juvenile adjudications (offenses where you were adjudicated delinquent in a juvenile court).
1b. Has the business entity or any owner, partner, officer or director of the business entity, or member or manager of a limited liability company
been convicted of, or is currently charged with, committing a FELONY or had a judgment withheld or deferred for a FELONY which has
not been previously reported to this insurance department?
If you have a felony conviction involving dishonesty or breach of trust, have you applied for written consent to engage in the business of
N/A
insurance in your home state as required by 18 USC 1033?
If so, was consent granted? (Attach copy of 1033 consent approved by home state.)
1c. Has the business entity or any owner, partner, officer or director of the business entity, or member or manager of a limited liability company
been convicted of, or is currently charged with a MILITARY OFFENSE which has not been previously reported to this insurance
department?
NOTE: For Questions 1a, 1b, and 1c, “Convicted” includes, but is not limited to, having been found guilty by verdict of a judge or jury, having entered a plea of guilty or nolo contendere or no contest, or having been given probation, a suspended sentence, or a fine.
If you answered “Yes” to any of the above questions (1a, 1b, or 1c), you must attach to this application:
a)a written statement explaining the circumstances of each incident,
b)a copy of the charging document, and
c)a copy of the official document, which demonstrates the resolution of the charges or any final judgment.
INS3213 (Rev. 02/2021)
Page 1 of 3
Ohio Department of InsuranceBUSINESS ENTITY TPA LICENSE RENEWAL/CONTINUATION
Background Questions (continued)
2. Has the business entity or any owner, partner, officer or director, or manager or member of a limited liability company, been named or
involved as a party in an administrative proceeding regarding any professional or occupational license or registration, which has not been previously reported to this state?
“Involved” means having a license censured, suspended, revoked, canceled, terminated; or, being assessed a fine, placed on probation or surrendering a license to resolve an administrative action. “Involved” also means being named as a party to an administrative or arbitration proceeding, which is related to a professional or occupational license. “Involved” also means having a license application denied or the act of withdrawing an application to avoid a denial. You may exclude terminations due solely to noncompliance with continuing education requirements or failure to pay a renewal fee.
If “Yes”, you must attach to this application:
a)a written statement identifying the type of license; identifying all parties involved (including their percentage of ownership, if any) and explaining the circumstances of each incident,
b)a copy of the Notice of Hearing or other document that states the charges and allegations, and
c)a copy of the official document which demonstrates the resolution of the charges or any final judgment.
3.
Does the TPA hold a fidelity bond or other comparable insurance policy coverage for all employees as required by R.C. 3959.11 and
OAC 3901-8-05 (D) (5)?
If “Yes”, provide a copy of bond or insurance policy coverage. Make sure documentation includes the name of the carrier, policy number
and effective dates.
4.
Does the TPA carry any type of professional liability and/or E&O insurance for TPA activities as required by ERISA?
If “Yes”, provide proof of coverage or bond. Make sure documentation includes the name of the carrier, policy number and effective dates.
5.
Do you understand that any required bond, insurance policy, professional liability and E&O insurance policy must be maintained for
the duration of the licensure period?
6.Will the TPA’s records continue to be maintained in accordance with the requirements of OAC 3901-8-05 (L) and (M)? If the
answer to any of the questions below is “No”, then attach a letter stating how those records are maintained.
a)
Records reflect all administered transactions?
b)
Detailed preparation or journalizing and posting of books and records are maintained?
c)
Records are maintained throughout the term of the administration agreement?
d)
All disbursement records contain the information required by R.C. 3959.15 (E)-(H)?
e)
Annual reports are required to be filed with insurers and plan sponsors within 90 days of the end of each fiscal year of the plan?
f)
Return premiums or contributions are paid to insurer or plan sponsors within 30 days of receipt?
7.
Since the last application or renewal have any Excess Insurers (Stop-Loss Carriers) or Managing General Underwriters approved the TPA to
administer claims for plans using their stop-loss products?
If “Yes”, provide the names and contact information for each one on a separate document.
8.
Since the last application or renewal has the TPA been licensed as a Managing General Agent?
If “Yes”, provide a name of the States and license status on a separate document.
9.
What type(s) of claims will the TPA administer or plan to administer within the next year in this state?
(Must check at least one option – Select all appropriate options that apply)
Traditional self-insured employee benefit plans
Government self-insured employee benefit plans
Preferred Provider Org. (PPO)
Fully insured employee benefit plans
Prescription drug claims
Provider billing processing
Life insurance claims
Medical/Managed care
Disability insurance claims
Other, attach description on a separate document.
Dental claims
10. How does the TPA handle plan sponsor and insurer funds?
Accounts are owned by the insurance company
Plan sponsor owns accounts/TPA has check writing ability
TPA has a separate fiduciary account(s) for plan sponsor & insurer funds
OTHER: Attach a letter of explanation.
11. Does the applicant understand that the TPA and its officers shall be responsible for the supervision of the actions of any and all personnel
and subcontractors who adjust or settle claims on behalf of the applicant according to OAC 3901-8-05 (E)(3)?
Applicant’s Signature:
12.
Does the applicant understand that the TPA may not commingle among its personal assets, or draw against for its own purposes, any
monies or contributions of a plan sponsor or plan participant according to OAC 3901-8-05 (H)(1)?
13.
Have there been any changes of officers, directors, partners, members or trustees, or any change of shareholders or other owners or
members holding 5% or more ownership in the TPA or change of business address that has not been previously reported to the Department
as required by OAC 3901-8-05(D)(5)?
If “Yes”, include the Department’s document for business entity changes.
14.
Is the TPA operating as a Pharmacy Benefit Manager (PBM)?
Applicant’s Certification and Attestation
21
On behalf of the business entity or limited liability company, the undersigned owner, partner, officer or director of the business entity, or member or manager of a limited liability company, hereby certifies, under penalty of perjury, that:
1.All of the information submitted in this application and attachments is true and complete and I am aware that submitting false information or omitting pertinent or material information in connection with this application is grounds for license or registration revocation and may subject me and the business entity or limited liability company to civil or criminal penalties.
2.Unless provided otherwise by law or regulation of the jurisdiction, the business entity or limited liability company hereby designate the Commissioner, Director or Superintendent of Insurance, or other appropriate party in each jurisdiction for which this application is made to be its agent for service of process regarding all insurance matters in the respective jurisdiction and agree that service upon the Commissioner, Director or Superintendent of Insurance, or other appropriate party of that jurisdiction is of the same legal force and validity as personal service upon the business entity.
3.The business entity or limited liability company grants permission to the Commissioner, Director or Superintendent of Insurance, or other appropriate party in each jurisdiction for which this application is made to verify information with any federal, state or local government agency, current or former employer, or insurance company.
4.Every owner, partner, officer or director of the business entity, or member or manager of a limited liability company, either (a) does not have a current child-support obligation, or (b) has a child-support obligation and is currently in compliance with that obligation.
5.I authorize the jurisdictions to give any information concerning me, as permitted by law, to any federal, state or municipal agency, or any other organization and I release the jurisdictions and any person acting on their behalf from any and all liability of whatever nature by reason of furnishing such information.
6.I acknowledge that I understand and will comply with the insurance laws and regulations of the jurisdictions to which I am applying for licensure/registration.
7.For Non-Resident License Applications, I certify that I am licensed and in good standing in my home state/resident state for the lines of authority requested from the non-resident state.
8.I hereby certify that upon request, I will furnish the jurisdiction(s) to which I am applying, certified copies of any documents attached to this application or requested by the jurisdiction(s).
Must be signed by an officer, director, or partner of the business entity, or member or manager if a limited liability company who has authority to act on behalf of the business entity:
Signature
Type or Print Name
Title
Address
Date
Social Security Number
City
State
Zip
Application Attachments
22The following attachments must accompany the application; otherwise the application may be returned unprocessed or considered deficient.
1.Non-refundable fee (check or money order) made payable to the “State of Ohio Treasurer” in the amount of $300.00;
2.Provide proof of fidelity bond or other comparable insurance policy coverage for all employees as required by R.C. 3959.11 and OAC 3901-8-05 (D)(5). (Documentation must include the name of the carrier, policy number and effective dates.)
3.Provide proof of professional liability insurance coverage and/or E&O insurance as required by ERISA. (Documentation must include the name of the carrier, policy number and effective dates.); and
4.If necessary, any required supporting details or documents.
Requirements for Licensure
23
1.All business entity TPA applicants must be registered with the Ohio Secretary of State.
2.Non-Resident TPA applicants must be registered with the home state Secretary of State.
Page 3 of 3
How Do I Get a Copy of My Workers' Comp Certificate - Facilitates the involvement of third parties in the claims process at the request of the claimant, for better support and assistance.
The process of transferring ownership can be made simpler with the use of a properly filled Arizona Tractor Bill of Sale. This legal document is crucial for both the buyer and the seller as it provides a clear record of the transaction, detailing all necessary information about the parties involved and the specifics of the tractor. For those looking for an efficient way to obtain this important form, Arizona PDFs offers a convenient template.
Ohio Overweight Permits - Ensuring employers meet legal requirements for workers' compensation, the OS-24 form includes notices, authorizations, and safety and health protection posters for workplace compliance.