N.H. Code Admin. R. Lab 408.18 – Application Form

(a) TPAs wishing to do business in this state shall complete and submit “Application for Certificate of Authority Third Party Administrators” form WC-TPA-COA (06/2019). The “Application for Certificate of Authority Third Party Administrators” form may be obtained at https://www.nh.gov/labor/documents/tpa-certificate-authority.pdf.
(b) In addition to the “Application for Certificate of Authority Third Party Administrators”, TPA’s shall include the following documentation with their submission:
1. (1) The last 3 years of federal tax returns;
2. (2) The last 2 years of audited financial statements;
3. (3) Certified copies of organizational documents;
4. (4) Certified copies of by-laws;
5. (5) Current adjusters licenses for workers’ compensation in NH;
6. (6) Business plan statement;
7. (7) Summary of insurance policies; and
8. (8) Evidence of a toll-free telephone number.
(c) The “Application for Certificate of Authority Third Party Administrators” form shall be completed and signed by an officer or authorized representative of the TPA. The complete application form shall be verified and filed with the department on initial application and annually thereafter. The filing fee of $200.00 shall accompany the initial application, and a filing fee of $100.00 shall accompany a renewal application.
(d) The “Application for Certificate of Authority Third Party Administrators” form shall not be deemed to be filed until the commissioner has received all of the information necessary to properly process the application.
(e) The “Application for Certificate of Authority Third Party Administrators” form completed by a corporation, limited partnership, or limited liability company shall be accompanied by a current certificate of good standing, from the secretary of state of New Hampshire.
(f) In addition to “The Application for Certificate of Authority Third Party Administrators” form the officer or authorized representative of the TPA shall complete and submit the “Biographical Affidavit” form WC-TPA-BA (3/2019). The “Biographical Affidavit” form may be obtained at https://www.nh.gov/labor/documents/tpa-affadavit.pdf.
(g) The “Biographical Affidavit” form must be signed before a notary public/justice of the peace in order to be considered properly submitted.
(h) Upon receipt of a completed application in accordance with (a) through (g) the commissioner shall make a determination on approval.
Source. #7142, eff 11-24-99, EXPIRED: 11-24-07
New. #9878-B, eff 2-25-11; ss by #12815, eff 6-26-19
APPENDIX
Rule
Specific State Statute which the Rule Implements
Lab 401.01
RSA 281-A:5, III; RSA 281-A:5-a
Lab 402.01
RSA 281-A:5-a
Lab 402.02
RSA 281-A:5-a
Lab 402.03
RSA 281-A:5, III; RSA 281-A:5-a
Lab 402.04
RSA 281-A:2, XII
Lab 402.05
RSA 281-A:5-a
Lab 402.06
RSA 281-A:5
Lab 402.07
RSA 281-A:5-b
Lab 402.08
RSA 281-A:5-a; RSA 281-A:5-b
Lab 402.09
RSA 281-A:5-a; RSA 281-A:5-b
Lab 402.10
RSA 281-A:5; RSA 281-A:5-a; RSA 281-A:5-b
Lab 402.11
RSA 281-A:5
Lab 402.12
RSA 281-A:5; RSA 281-A:11
Lab 402.13
RSA 281-A:5-a; RSA 281-a:5-b
Lab 402.14
RSA 281-A:5-a; RSA 281-A:5-b
Lab 402.15
RSA 281-A:5-a; RSA 281-A:5-b; RSA 281-A:5-c
Lab 402.16
RSA 281-A:5-a; RSA 281-A:5-b
Lab 403.01
RSA 281-A:5, III; RSA 281-A:5-a; RSA 281-A:5-b;
RSA 281-A:5-c
Lab 403.02
RSA 281-A:5-c
Lab 403.03
RSA 281-A:5-a; RSA 281-A:5-b; RSA 281-A:5-c
Lab 403.04
RSA 281-A:7
Lab 404
RSA 281-A:2, VIII, XI; RSA 281-A:5-a; RSA 281-A:5-c;
RSA 281-A:5, III; RSA 281-A:7
Lab 405.01
RSA 281-A:5, III; RSA 281-A:5-a
Lab 405.02
RSA 281-A:5, III; RSA 281-A:5-a; RSA 281-A:5-b;
RSA 281-A:5 –c
Lab 405.03-Lab 405.04
RSA 281-A:5, I, III; RSA 281-A:5-a; RSA 281-A:5-b;
RSA 281-A:5-c
Lab 406-407
Repealed
Lab 408
RSA 281-A:5-d, RSA 281-A:60, I (r).