Applicant Company Name:
Required Filing Checklist (Information should be emailed to email@example.com with wording Supporting Documents and "name of TPA" in the subject line):
$400 Filing Fee paid upon submission (effective July 1, 2019)i
All basic organizational documents:
a. Certified Articles of Incorporationii
b.Certified Bylaws, Rules, Regulations
c. Entity(s) Organizational
d. Articles of Association
e. Partnership Agreement
f. Trade Name Certificate
g. Trust Agreement
h. Shareholder Agreement
1. List of Officers
Officers Organizational Chart
NAIC Biographical Affidavit
2. Original Letter of Certification or Certificate of Good Standingiii
3. Certificate of Good Standing issued by the Kansas Secretary of Stateiv
4. Two (2) most recent fiscal years’ Audited Financial Statementsv
5. Third Party Administrator Hardship Exemption Request K.S.A. 3812(b)(5)
6.Detailed Business Plan in the State of Kansasvi
7. Letter of good standing from Financial Institutionvii
8. List of Insurers
i. Filing Fee will be paid when submitting the application.
ii. A. Articles of Incorporation must be accompanied by original certification by the proper supervisory official of the Company’s state of incorporation.
B. Amended Bylaws are required to have an original certification by the corporate secretary with the company’s seal or notarized.
iii. Must be issued by the Secretary of State or Department of Insurance where the company is incorporated.
iv. Issued by the Kansas Secretary of State.
v. K.S.A. 40-3812(b)(4): “Audited financial statements or reports for the two most recent fiscal years that demonstrate that the applicant has a positive net worth. If the applicant has been in existence for less than two fiscal years, the uniform application shall include financial statementsor reports, certified by at least two officers, owners or directors of the applicant and prepared in accordance with GAAP, for any completed fiscal years and for any month during the current fiscal year for which such financial statements or reports have been completed. An audited annual financial report prepared on a consolidated basis shall include a columnar consolidating or combining worksheet that shall be filed with the report…”.
vi. K.S.A. 40-3812(b)(6): “A statement describing the business plan, including information on staffing levels and activities, proposed in this state and nationwide. The plan shall provide details setting forth the applicant’s capability for providing a sufficient number of experienced and qualified personnel in the areas of claims processing, record keeping and underwriting.”
vii. Letter should be addressed to the Kansas Insurance Department and includes the accounts the company has with the bank, the purpose of the accounts, and that the accounts are in goodstanding.