Third Party Administrator (Life/Health)
|TPA Renewal Application Checklist||
Due Date: March 1.
You may submit your renewal application after January 1, but the renewal application must be received by the Department of Insurance by March 1.
|TPA Application Instructions|
|TPA Application Requirements/Process||
Arizona law requires Life and Health Administrators operating in this state to be registered with the Arizona Department of Insurance, unless they are exempt by statute (A.R.S. §20-485.12 et seq.). Life and Health Administrators are more commonly referred to as third party administrators (TPA).
There is not a separate application procedure for resident versus non-resident TPA applicants in Arizona. One application process applies to both.
|Form 100: TPA Application||
Must be completed, verified and notarized by an officer of the applicant.
|Form 100.A: TPA Application Addendum||
Identifies the type(s) of services the administrator will provide.
|Form E110(L-H): Biographical Affidavit||
Must be completed by each partner, officer, and director, and each other individual owning 10% or more of the applicant. ARS § 20-485.12(B)(5)
|Form 111: TPA Financial Statement||
Must be certified by two officers of the applicant. Must be current within 90 days of application filing date. ARS § 20-485.12(B)(1)(a) and (b)
|Form L157: TPA Bond of Administrator||
Face amount must equal the greater of either (A) 10% of total funds handled for life and health coverage of Arizona residents, or (B) $5,000. Funds handled includes premiums collected for and/or claims paid on behalf of an insurer. Submit with power of attorney. ARS § 20-485.10
|Life and Health Administrator (TPA) Arizona Requirements|