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Please tab each item to correspond with its number of the required item below. All materials are to be sent postal mail, no emailed or faxed materials will be accepted.
1. Completed Resident TPA Application. Each application question must be completed entirely.
2. Licensure fee of $50. (Checks made payable to IDOI)
3. Copies of all basic organizational documents, including any articles of incorporation, articles of association, partnership agreement, trade name certificate, trust agreement, shareholder agreement and other applicable documents and all amendments to those documents.
4. Provide copies of all bylaws, rules, regulations or similar documents regulating the internal affairs of the administrator.
5. Audited Financial Statement prepared by an independent certified public accountant for the two most recent fiscal years (if the applicant has been in business for less than two years, submit financial reports that have been prepared in accordance with GAAP and certified by an officer of the applicant).
6. Statement describing the applicant's business plan (must include informaiton on staffing levels and activites proposed in this state and nationwide).
7. A list of the current officers, directors or partners of the administrator
8. Biographical Affidavits for each officer, director or partner of the administrator. Each affidavit must be originally signed, notarized and dated within twelve (12) months of the application.
9. Copies of all administrative agreements along with the Compliance Checklist. Each agreement should be highlighted to correspond with the citations of the checklist.
10. If the administrator is administering a Governmental Plan and/or Church Plan a Surety Bond is required.
10.(a) A report detailing the total funds administered for a Governmental Plan and/or Church Plan for Indiana and all other jurisdictions combined.
The completed application, and information requested above ,should be mailed to the following:
Indiana Department of Insurance
311 West Washington Street, Suite 300
Indianapolis, Indiana 46204-2787
Emailed or faxed materials will not be accepted
After a complete filing has been approved, the Department will issue a license and send it to the contact person listed on the application.
NOTE: Any TPA licensed before June 1st must renew their license before August 31st of the same year.