The Ohio Ins3213 form is a comprehensive document designed for business entities seeking to obtain or renew a Third-Party Administrator (TPA) license within the state of Ohio. This form, under the guidance of Judith L. French, Director, requires applicants to provide detailed information about their business, including demographic details, designated responsible licensed producers, and background questions to ensure compliance with Ohio’s insurance regulations. Moreover, it outlines the necessary checks for criminal backgrounds, insurance coverage, and regulatory compliance essential for operating as a TPA in Ohio.
In the realm of insurance regulation, accuracy and compliance with state-specific requirements are paramount. Among the numerous documents and forms that anchor the regulatory framework, the Ohio Ins3213 form stands out for businesses operating within the insurance sector. Drafted under the auspices of the Ohio Department of Insurance, this comprehensive document serves as a critical tool for both resident and non-resident business entities seeking licensure for insurance-related activities. Designed meticulously, it encompasses sections for basic demographic data of the applying entity, including business name, Federal Employer Identification Number (FEIN), and contact details, underscoring the need for clarity and transparency. Furthermore, the form delves into areas probing the background of the business, such as past convictions of associated personnel, involvement in professional or occupational license proceedings, and adherence to financial responsibilities. Also notable is the requirement for disclosing any affiliations with financial institutions, alongside mandated insurance coverage details, thereby ensuring both integrity and adequacy of financial protections in place. The designated responsible licensed producer section heightens accountability by mandating the identification of individuals responsible for compliance with state laws, thereby weaving a tight regulatory fabric designed to protect policyholders and maintain market stability. Additional considerations include the submission of attachments concerning fiduciary responsibilities, bond or insurance policy documentation, and changes in business structure or licensing status. The solemnity of this application process is punctuated by the certification and attestation section, compelling applicants to pledge accuracy, compliance, and transparency under penalty of perjury. Through its exhaustive scope and detailed requirements, the Ohio Ins3213 form embodies the rigorous standards set forth by the state to oversee the conduct and integrity of third-party administrators and insurance entities within its jurisdiction.
Judith L. French, Director
Check appropriate boxes for license requested:
(Please Print or Type)
Resident License
Non-Resident License
Identify Home State:
Identify Home State License #:
Demographic Information
1Business Entity’s Name
2FEIN
3Ohio License Number
4National Producer Number (NPN)
5 Is the business entity affiliated with a financial institution/bank?
Yes
No
6Business Address
7City
8State
9Zip or Foreign Country
10Phone Number (include extension)
11Fax Number
12Business E-Mail Address
13Business Web Site Address
14Mailing Address
15P.O. Box
16City
17State
18Zip or Foreign County
Designated/Responsible Licensed Producer
19Identify at least one Designated/Responsible Licensed Producer responsible for the business entity’s compliance with the insurance laws, rules, and regulations of this state:
Name
SSN
NPN
Background Questions
20
1a. Has the business entity or any owner, partner, officer or director of the business entity, or member or manager of a limited liability company
been convicted of, or is currently charged with, committing a MISDEMEANOR or had a judgment withheld or deferred for a
MISDEMEANOR which has not been previously reported to this insurance department?
You may exclude the following misdemeanor convictions or pending misdemeanor charges: traffic citations, driving under the influence
(DUI), driving while intoxicated (DWI), driving without a license, reckless driving, or driving with a suspended or revoked license.
You may also exclude juvenile adjudications (offenses where you were adjudicated delinquent in a juvenile court).
1b. Has the business entity or any owner, partner, officer or director of the business entity, or member or manager of a limited liability company
been convicted of, or is currently charged with, committing a FELONY or had a judgment withheld or deferred for a FELONY which has
not been previously reported to this insurance department?
If you have a felony conviction involving dishonesty or breach of trust, have you applied for written consent to engage in the business of
N/A
insurance in your home state as required by 18 USC 1033?
If so, was consent granted? (Attach copy of 1033 consent approved by home state.)
1c. Has the business entity or any owner, partner, officer or director of the business entity, or member or manager of a limited liability company
been convicted of, or is currently charged with a MILITARY OFFENSE which has not been previously reported to this insurance
department?
NOTE: For Questions 1a, 1b, and 1c, “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 contendere or no contest, or having been given probation, a suspended sentence, or a fine.
If you answered “Yes” to any of the above questions (1a, 1b, or 1c), you must attach to this application:
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.
INS3213 (Rev. 02/2021)
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Ohio Department of InsuranceBUSINESS ENTITY TPA LICENSE RENEWAL/CONTINUATION
Background Questions (continued)
2. Has the business entity or any owner, partner, officer or director, or manager or member of a limited liability company, been named or
involved as a party in an administrative proceeding regarding any professional or occupational license or registration, which has not been previously reported to this state?
“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 “Yes”, you must attach to this application:
a)a written statement identifying the type of license; identifying all parties involved (including their percentage of ownership, if any) 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.
3.
Does the TPA hold a fidelity bond or other comparable insurance policy coverage for all employees as required by R.C. 3959.11 and
OAC 3901-8-05 (D) (5)?
If “Yes”, provide a copy of bond or insurance policy coverage. Make sure documentation includes the name of the carrier, policy number
and effective dates.
4.
Does the TPA carry any type of professional liability and/or E&O insurance for TPA activities as required by ERISA?
If “Yes”, provide proof of coverage or bond. Make sure documentation includes the name of the carrier, policy number and effective dates.
5.
Do you understand that any required bond, insurance policy, professional liability and E&O insurance policy must be maintained for
the duration of the licensure period?
6.Will the TPA’s records continue to be maintained in accordance with the requirements of OAC 3901-8-05 (L) and (M)? If the
answer to any of the questions below is “No”, then attach a letter stating how those records are maintained.
a)
Records reflect all administered transactions?
b)
Detailed preparation or journalizing and posting of books and records are maintained?
c)
Records are maintained throughout the term of the administration agreement?
d)
All disbursement records contain the information required by R.C. 3959.15 (E)-(H)?
e)
Annual reports are required to be filed with insurers and plan sponsors within 90 days of the end of each fiscal year of the plan?
f)
Return premiums or contributions are paid to insurer or plan sponsors within 30 days of receipt?
7.
Since the last application or renewal have any Excess Insurers (Stop-Loss Carriers) or Managing General Underwriters approved the TPA to
administer claims for plans using their stop-loss products?
If “Yes”, provide the names and contact information for each one on a separate document.
8.
Since the last application or renewal has the TPA been licensed as a Managing General Agent?
If “Yes”, provide a name of the States and license status on a separate document.
9.
What type(s) of claims will the TPA administer or plan to administer within the next year in this state?
(Must check at least one option – Select all appropriate options that apply)
Traditional self-insured employee benefit plans
Government self-insured employee benefit plans
Preferred Provider Org. (PPO)
Fully insured employee benefit plans
Prescription drug claims
Provider billing processing
Life insurance claims
Medical/Managed care
Disability insurance claims
Other, attach description on a separate document.
Dental claims
10. How does the TPA handle plan sponsor and insurer funds?
Accounts are owned by the insurance company
Plan sponsor owns accounts/TPA has check writing ability
TPA has a separate fiduciary account(s) for plan sponsor & insurer funds
OTHER: Attach a letter of explanation.
11. Does the applicant understand that the TPA and its officers shall be responsible for the supervision of the actions of any and all personnel
and subcontractors who adjust or settle claims on behalf of the applicant according to OAC 3901-8-05 (E)(3)?
Applicant’s Signature:
12.
Does the applicant understand that the TPA may not commingle among its personal assets, or draw against for its own purposes, any
monies or contributions of a plan sponsor or plan participant according to OAC 3901-8-05 (H)(1)?
13.
Have there been any changes of officers, directors, partners, members or trustees, or any change of shareholders or other owners or
members holding 5% or more ownership in the TPA or change of business address that has not been previously reported to the Department
as required by OAC 3901-8-05(D)(5)?
If “Yes”, include the Department’s document for business entity changes.
14.
Is the TPA operating as a Pharmacy Benefit Manager (PBM)?
Applicant’s Certification and Attestation
21
On behalf of the business entity or limited liability company, the undersigned owner, partner, officer or director of the business entity, or member or manager of a limited liability company, hereby certifies, under penalty of perjury, that:
1.All of the information submitted in this 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 business entity or limited liability company to civil or criminal penalties.
2.Unless provided otherwise by law or regulation of the jurisdiction, the business entity or limited liability company hereby designate the Commissioner, Director or Superintendent of Insurance, or other appropriate party 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 Insurance, or other appropriate party of that jurisdiction is of the same legal force and validity as personal service upon the business entity.
3.The business entity or limited liability company grants permission to the Commissioner, Director or Superintendent of Insurance, or other appropriate party in each jurisdiction for which this application is made to verify information with any federal, state or local government agency, current or former employer, or insurance company.
4.Every owner, partner, officer or director of the business entity, or member or manager of a limited liability company, 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 jurisdictions to give any information concerning me, as permitted by law, 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 understand and will comply with the insurance laws and regulations of the jurisdictions to which I am applying for licensure/registration.
7.For Non-Resident License Applications, I certify that I am licensed and in good standing in my home state/resident state for the lines of authority requested from the non-resident state.
8.I hereby certify that upon request, I will furnish the jurisdiction(s) to which I am applying, certified copies of any documents attached to this application or requested by the jurisdiction(s).
Must be signed by an officer, director, or partner of the business entity, or member or manager if a limited liability company who has authority to act on behalf of the business entity:
Signature
Type or Print Name
Title
Address
Date
Social Security Number
City
State
Zip
Application Attachments
22The following attachments must accompany the application; otherwise the application may be returned unprocessed or considered deficient.
1.Non-refundable fee (check or money order) made payable to the “State of Ohio Treasurer” in the amount of $300.00;
2.Provide proof of fidelity bond or other comparable insurance policy coverage for all employees as required by R.C. 3959.11 and OAC 3901-8-05 (D)(5). (Documentation must include the name of the carrier, policy number and effective dates.)
3.Provide proof of professional liability insurance coverage and/or E&O insurance as required by ERISA. (Documentation must include the name of the carrier, policy number and effective dates.); and
4.If necessary, any required supporting details or documents.
Requirements for Licensure
23
1.All business entity TPA applicants must be registered with the Ohio Secretary of State.
2.Non-Resident TPA applicants must be registered with the home state Secretary of State.
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Completing the Ohio INS3213 form is a critical step for business entities seeking to renew or continue their Third-Party Administrator (TPA) license in the state. This process ensures compliance with Ohio's insurance regulations and standards. Proper and accurate completion of the form aids in maintaining the integrity of the insurance operations within Ohio. Below are step-by-step instructions designed to guide through the completion of the INS3213 form.
Once completed, review the entire form to ensure all required fields are filled out and attachments are included. Submitting a complete and accurate form is essential for the timely processing of your TPA license renewal or continuation in Ohio. This diligence ensures compliance and uninterrupted operation within the state's regulatory environment.
What is the Ohio INS3213 form used for?
The Ohio INS3213 form is designed primarily for business entities that are applying to become Third Party Administrators (TPAs) for insurance purposes or are renewing/continuing their TPA license in the state of Ohio. This form allows an entity to provide all necessary information regarding its business operations, affiliation with financial institutions, background information of its owners, directors, or partners, and compliance with Ohio insurance laws and regulations. Moreover, it's crucial for demonstrating the entity's ability to handle funds, manage records correctly, and maintain mandatory insurance coverages.
Who needs to fill out the Ohio INS3213 form?
Any business entity that wishes to operate as a Third Party Administrator within Ohio or continue its operations in such capacity must fill out the INS3213 form. This includes entities already holding a TPA license and seeking renewal as well as new entities applying for a license to offer such services in Ohio. It's important for entities involved in handling insurance claims, plan sponsor funds, or who are associated in some way with the administration of insurance benefits to comply by submitting this form accurately.
Are there any specific exclusions when reporting misdemeanors or felonies on the INS3213 form?
Yes, when answering background questions related to misdemeanors or felonies on the INS3213 form, certain misdemeanors are excluded from being reported. Specifically, traffic citations, DUI, DWI, driving without a license, reckless driving, or driving with a suspended or revoked license do not need to be disclosed. Furthermore, juvenile adjudications (offenses adjudicated in juvenile court) are also excluded. However, any felony conviction, especially those involving dishonesty or breach of trust, must be reported unless they fit the exclusions outlined.
What attachments are required with the Ohio INS3213 form?
Alongside the completed Ohio INS3213 form, applicants must attach a non-refundable fee payment, proof of fidelity bond or comparable insurance policy coverage for all employees, proof of professional liability and/or E&O insurance coverage as per ERISA requirements, and any supporting documents necessary for the application. If there are any positive responses to the background questions, detailed explanations along with the pertinent legal documents must also be attached.
How does a business entity apply for a Non-Resident License using the INS3213 form?
Non-resident business entities looking to apply for a license in Ohio must fill out the INS3213 form indicating they are applying for a Non-Resident License. They must also prove they are licensed and in good standing in their home state for the lines of authority requested from Ohio. This includes providing all necessary paperwork just as a resident applicant would, including proof of registration with their home state's Secretary of State.
What is the importance of fidelity bonds and insurance coverages as stated in the INS3213 form?
Fidelity bonds and professional liability/E&O insurance coverages are critical for TPA entities, as they ensure the entity is financially capable of covering losses or damages that may arise in the course of handling insurance claims or funds. These requirements protect both the TPA entity and its clients from unforeseen financial risks and are mandatory for maintaining an active TPA license in Ohio.
What happens if there are changes in the business entity's information after submitting the INS3213 form?
If there are any changes to the business entity's information, such as a change in officers, directors, partners, members, shareholders with 5% or more ownership, or the business address, after the submission of the INS3213 form, it is crucial to report these changes to the Ohio Department of Insurance as required by the OAC 3901-8-05 (D)(5). Failure to report significant changes could affect the status of the TPA license and may lead to regulatory issues.
Completing the Ohio INS3213 form, crucial for business entities seeking to renew or continue their Third-Party Administrator (TPA) license, requires careful attention to detail to avoid common pitfalls. Here are seven mistakes often made when filling out this form:
Incorrectly Identifying License Type: Applicants frequently miss marking the correct box to indicate whether they are applying for a Resident or Non-Resident License. This seemingly minor oversight can lead to processing delays or the outright rejection of the application.
Incomplete Demographic Information: Not providing full demographic information, such as the Business Entity's Name, FEIN, or National Producer Number (NPN), risks the application being considered incomplete. Every detail requested in sections 1 through 14 plays a critical role in the application’s review.
Overlooking Background Questions: Failure to accurately respond to the background questions in section 20 can have serious repercussions. It is imperative that applicants disclose any misdemeanor or felony convictions, excluding the exemptions outlined, to ensure transparency and compliance with the law.
Omitting Required Attachments: Applicants often forget to attach necessary documents, such as proof of fidelity bond, professional liability insurance coverage, or E&O insurance, as specified in section 22. These documents are essential for demonstrating compliance with state regulations.
Misunderstanding Insurance Funds Management: A common error is incorrectly indicating how the TPA handles plan sponsor and insurer funds. Clarifying whether accounts are owned by the insurance company or if the TPA possesses check-writing ability is crucial for regulatory compliance.
Signature Discrepancies: The application must be signed by an individual with sufficient authority, such as an officer, director, or partner of the business entity. An incorrect or missing signature can invalidate the entire application.
Ignoring Licensure Prerequisites: A notable oversight is failing to ensure that all business entity TPA applicants are properly registered with the Ohio Secretary of State or, for Non-Resident TPA applicants, with the home state Secretary of State as required. This registration is a fundamental requirement for the application process.
Addressing these common mistakes when completing the Ohio INS3213 form can greatly increase the chances of a smooth and successful application process for business entities seeking TPA licensure.
Navigating the landscape of licensure and regulatory compliance for third-party administrators (TPAs) in Ohio requires paying close attention to various forms and documents that complement the Ohio Ins3213 form. These are essential for ensuring full compliance with the Ohio Department of Insurance and other regulatory bodies. Below, we shed light on five critical documents often used in conjunction with the Ohio Ins3213 form to streamline the licensure or renewal process, maintain legal compliance, and support the operational needs of businesses in the insurance sector.
In essence, accurately completing and submitting the Ohio Ins3213 form along with these crucial supporting documents ensures that TPAs meet the state’s stringent requirements for operation. These additional forms and documents are not just paperwork; they represent integral components of the trust, compliance, and professionalism that underscore the insurance industry in Ohio. Understanding and fulfilling these requirements is not merely a legal obligation but a foundation for building a reputable and resilient business.
The Ohio Ins3213 form, used by business entities to apply or renew their Third Party Administrator (TPA) license in Ohio, shares similarities with the Uniform Application for Business Entity Insurance License/Registration form. Both documents require detailed information about the business entity, including demographic details, licensing data, and the identification of those responsible for the entity's compliance with state regulations. They serve to inform regulatory bodies about the business's operations and compliance mechanisms, ensuring adherence to state laws and protection of consumer interests.
Similarly, the Ohio Ins3213 form parallels the Individual Insurance Producer License Application, where individuals instead of business entities provide personal identification, undergo background checks, and attest to their compliance with state insurance laws and regulations. Although targeting individuals, this form similarly demands transparency regarding criminal history and compliance with professional standards, aiming to maintain the integrity of insurance services and protect consumer interests within the state.
Another comparable document is the Financial Institution Bond, used by businesses to provide proof of fidelity bond coverage, a requirement also seen in the Ohio Ins3213 form for TPAs. Both documents necessitate disclosing the bonding company's information and coverage specifics, underlining the priority given to financial security and fraud prevention in business operations related to financial and insurance services.
The Professional Liability Insurance Evidence form bears resemblance as well, as it's used by entities to prove they hold required error and omission (E&O) coverage, akin to one of the stipulations in the Ohio Ins3213 form. This alignment underscores the regulatory emphasis on ensuring businesses are equipped to handle liabilities and protect consumers from potential professional oversights or errors in service delivery.
Lastly, the Change of Address form for TPAs, while more narrowly focused, shares a core function with sections of the Ohio Ins3213 form. Both entail reporting critical operational updates to regulatory agencies, ensuring that records are current and reflective of the business's operational status and contact information. This practice facilitates efficient communication and oversight by regulatory bodies, crucial for maintaining orderly and compliant industry operations.
When completing the Ohio INS3213 form for a business entity TPA license renewal or continuation, attention to detail and adherence to regulatory requirements is paramount. To assist in this process, here are specific dos and don'ts to consider:
The Ohio INS3213 form is an essential document for business entities seeking licensure as Third-Party Administrators (TPAs) in the state of Ohio. However, several common misconceptions surround its completion and purpose. Addressing these misconceptions is crucial for ensuring accurate and compliant submissions by applicants.
Misconception 1: Only Ohio-based companies need to complete the INS3213 form. Both resident and non-resident TPAs must fill out this form. Non-resident applicants are required to be registered with their home state Secretary of State, emphasizing the form's broader applicability beyond Ohio-based entities.
Misconception 2: Background questions are invasive and unnecessary. The background questions on the INS3213 form serve a vital function in maintaining the integrity of the insurance industry. They are designed to identify any past criminal activities or administrative penalties that might affect an entity's suitability to handle fiduciary duties. The exclusion criteria for certain misdemeanors demonstrate a balanced approach to evaluating an applicant's past.
Misconception 3: The form is only concerned with insurance-related activities. While the primary focus of the INS3213 form is to ascertain the eligibility of TPAs to manage insurance claims and related activities, it also encompasses broader operational aspects. This includes the maintenance of records, handling of sponsor and insurer funds, and adherence to state and federal regulations, highlighting the comprehensive oversight intended by this licensure process.
Misconception 4: Submission of additional documentation is rarely necessary. The INS3213 form clearly specifies that additional documents are often needed alongside the application. These include, but are not limited to, proof of fidelity bond coverage, professional liability insurance, and, where relevant, any correspondence pertaining to a "Yes" answer in the background questions section. These requirements ensure that TPAs have appropriate risk mitigation measures in place.
Misconception 5: The application process is a one-time requirement for TPAs. The form must be completed not only at the initial point of application but also for renewal/continuation of a license. Moreover, the form requires disclosure of any significant changes since the last application, such as changes in ownership, management, or business address, ensuring ongoing compliance with regulatory standards.
Understanding the purpose, scope, and requirements of the Ohio INS3213 form is pivotal for business entities aiming to operate as TPAs within Ohio. Clearing up these misconceptions facilitates a smoother application process, promoting compliance and the safeguarding of consumer interests.
Understanding the Ohio INS3213 form and its implications is crucial for business entities operating within the insurance sector. Here are key takeaways to ensure compliance and proper form submission:
Adhering to these guidelines when completing and submitting the Ohio INS3213 form is not just about regulatory compliance; it's about establishing or maintaining a trustworthy standing within Ohio's insurance industry. Every section and requirement is designed to protect stakeholders, ensure operational integrity, and uphold high standards within the insurance profession.
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