Applicant Company Name: FEIN: Declared Home State (see below): K.S.A. 40-3813(b): "An administrator shall not be eligible for a nonresident administrator license under the provisions of this section if it does not hold a license in a home state that has adopted a substantially similar law governing administrators." Required Filing Checklist Information should be emailed to kid.tpa@ks.gov (with wording Supporting Documents and "name of TPA" in the subject line) $400 Filing Fee paid upon submission (effective July 1, 2019) Certificate of Good Standing issued by Declared Home State defined KSA 40-3813(b) Home State TPA License Declared Home State defined KSA 40-3813(b) Application Contact Information The following individual (company employee or paid consultant) is the authorized representative of the Applicant for this application. Name: Title: Company: Email: Phone: Non-Resident Third Party Administrator License Application Applicant Name: FEIN: Incorporation Date: DBA/TradeName (if appllicable): State of Incorporation: Country or Domicile: Statutory Home Office: City, State, Zip: Phone: Fax: Email: Admin/Business Address: City, State, Zip: Phone: Fax: Email: Mailng Address: City, State, Zip: Phone: Fax: Email: Owners, Partners, Officers and Directors Identify sole proprietor or all owners, partners and directors of the applicant (List only those owners with 10% or more ownership) Name: Title: % Ownership: Name: Title: % Ownership: Name: Title: % Ownership: Name: Title: % Ownership: Name: Title: % Ownership: Name: Title: % Ownership: Name: Title: % Ownership: Name: Title: % Ownership: Name: Title: % Ownership: Name: Title: % Ownership: Background Information Please read and answer the following questions: Yes No 1. Has the applicant or any owner, partner, officer or director ever been convicted of, or is the applicant or any owner, partner, officer or director currently charged with, committing a crime, whether or not adjudication was withheld? “Crime” includes a misdemeanor, felony or a military offense. You may exclude misdemeanor traffic citations and juvenile offenses. “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 contender, or having been given probation, a suspended sentence or a fine. If you answer yes, you must provide by email to kid.tpa@ks.gov 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. Yes No 2. Has the applicant or any owner, partner, officer or director ever been involved in an administrative proceeding regarding any professional or occupational license? “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 you answer yes, you must provide by email to kid.tpa@ks.gov a. a written statement identifying the type of license 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. Yes No 3. Has any demand been made or judgment rendered against the applicant or any owner, partner, officer or director for overdue monies by an insurer, insured, producer or anyone else or have you ever been subject to a bankruptcy proceeding? If you answer yes, you must provide by email to kid.tpa@ks.gov a. submit a statement summarizing the details of the indebtedness and arrangements for repayment. Yes No 4. Has the applicant or any owner, partner, officer or director ever been notified by any jurisdiction to which you are applying of any delinquent tax obligation that is not the subject of a repayment agreement? If you answer yes, identify the jurisdiction(s): Yes No 5. Is the applicant or any owner, partner, officer or director a party to, or ever been found liable in any lawsuit or arbitration proceeding involving allegations of fraud, misappropriation or conversion of funds, misrepresentation or breach of fiduciary duty? If you answer yes, you must provide by email to kid.tpa@ks.gov a. a written statement summarizing the details of each incident, b. a copy of the Petition, Complaint or other document that commenced the lawsuit or arbitration, and c. a copy of the official document which demonstrates the resolution of the charges or any final judgment Yes No 6. Has the applicant or any owner, partner, officer or director ever had a contract or any other business relationship terminated for any alleged misconduct? If you answer yes, you must provide by email to kid.tpa@ks.gov a. a written statement summarizing the details of each incident and explaining why you feel this incident should not prevent you from receiving an administrator license, and b. copies of all relevant documents. Applicant Certification and Attestation The undersigned owner, partner, officer or director of the applicant hereby certifies, under penalty of perjury, that: 1. All of the information submitted in the 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 applicant to civil or criminal penalties as determined by a court of law. 2. Where required by law, the applicant hereby designates the Commissioner, Director or Superintendent of Insurance, or an appropriate representative 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 that jurisdiction is of the same legal force and validity as personal service upon the applicant. 3. The applicant grants permission to the Commissioner, Director or Superintendent of Insurance in each jurisdiction for which this applicant is made to verify any information supplied with any federal, state,or local government agency, current or former employer or insurance company. 4. Every owner, partner, officer or director of the applicant 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 jurisdiction to give any information they may have concerning me 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 am familiar with the insurance laws and regulations of the jurisdiction to which I am applying for licensure/registration. 7. If required, I have received a Certificate of Good Standing from the jurisdiction’s Secretary of State in which I am applying. 8. K.S.A. 65-636; 65-1626a; and 65-1643 pertain to the practice of pharmacy and the use of titles like “pharmacy” or any other term designated to take the place of such title. Please check this box to indicate your compliance with the aforementioned Kansas statutes. Must be signed by an officer, director, principal or partner of the Applicant Signature: Date: 03/24/2023 By typing your name above, you are signing this electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this form. Printed Name: Title: Address: City/State/Zip:
