TPA Certification
Insured/SIR Client
Name of Insured/SIR Client
Contact at Insured/SIR Client
Broker
Broker Contact
Organization
Legal Name of Organization
Address
City
State
-- choose a state --
AL - Alabama
AK - Alaska
AZ - Arizona
AR - Arkansas
CA - California
CO - Colorado
CT - Connecticut
DE - Delaware
DC - District of Columbia
FL - Florida
GA - Georgia
HI - Hawaii
ID - Idaho
IL - Illinois
IN - Indiana
IA - Iowa
KS - Kansas
KY - Kentucky
LA - Louisiana
ME - Maine
MD - Maryland
MA - Massachusetts
MI - Michigan
MN - Minnesota
MS - Mississippi
MO - Missouri
MT - Montana
NE - Nebraska
NV - Nevada
NH - New Hampshire
NJ - New Jersey
NM - New Mexico
NY - New York
NC - North Carolina
ND - North Dakota
OH - Ohio
OK - Oklahoma
OR - Oregon
PA - Pennsylvania
PR - Puerto Rico
RI - Rhode Island
SC - South Carolina
SD - South Dakota
TN - Tennessee
TX - Texas
UT - Utah
VT - Vermont
VA - Virginia
WA - Washington
WV - West Virginia
WI - Wisconsin
WY - Wyoming
ZIP
County
Country
Claims Handling Office That Will Be Assigned to the Client
Address
City
State
-- choose a state --
AL - Alabama
AK - Alaska
AZ - Arizona
AR - Arkansas
CA - California
CO - Colorado
CT - Connecticut
DE - Delaware
DC - District of Columbia
FL - Florida
GA - Georgia
HI - Hawaii
ID - Idaho
IL - Illinois
IN - Indiana
IA - Iowa
KS - Kansas
KY - Kentucky
LA - Louisiana
ME - Maine
MD - Maryland
MA - Massachusetts
MI - Michigan
MN - Minnesota
MS - Mississippi
MO - Missouri
MT - Montana
NE - Nebraska
NV - Nevada
NH - New Hampshire
NJ - New Jersey
NM - New Mexico
NY - New York
NC - North Carolina
ND - North Dakota
OH - Ohio
OK - Oklahoma
OR - Oregon
PA - Pennsylvania
PR - Puerto Rico
RI - Rhode Island
SC - South Carolina
SD - South Dakota
TN - Tennessee
TX - Texas
UT - Utah
VT - Vermont
VA - Virginia
WA - Washington
WV - West Virginia
WI - Wisconsin
WY - Wyoming
ZIP
County
Country
Contact Information
Telephone Number
Fax Number
Email Address
Company Web Address
Company Information
Are you operating as a DBA in any state(s)?
Yes
No
If "Yes," please provide the complete DBA
name and state where the DBA was registered.
Annual Revenue (Last Full Year)
Number of Employees
Year Established
Entity Type
(choose one)
Corporation
Partnership
Sole Proprietor
LLC
Locations (check all that apply)
Check All
Alaska
Alabama
Arkansas
Arizona
California
Colorado
Connecticut
District of Columbia
Delaware
Florida
Georgia
Hawaii
Iowa
Idaho
Illinois
Indiana
Kansas
Kentucky
Louisiana
Massachusetts
Maryland
Maine
Michigan
Minnesota
Missouri
Mississippi
Montana
North Carolina
North Dakota
Nebraska
New Hampshire
New Jersey
New Mexico
Nevada
New York
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Virginia
Vermont
Washington
Wisconsin
West Virginia
Wyoming
Do you self-administer claims?
Yes
No
Claim Management
Claim Management/Reporting System Name
Claim Management/Reporting System Type
Vendor Hosted Application
Vendor Software
In-House System
Other
Is on-line access to your system available to carriers?
Yes
No
Are you able to provide aggregate erosion reporting?
Yes
No
Please upload sample erosion report
Lines of Business Capability
GL
Property
AL
Workers Comp
APD
Professional
Inland Marine
Products Liability
What are your offices' areas of expertise?
TPA Information
Please upload your TPA license(s) for all applicable states
Please upload the bios of the key individuals at the TPA or TPA location
Please upload any service standards or best practices documents
E&O Coverage
Please upload your proof of E&O coverage
Have you had any E&O claims in the last 5 years?
Yes
No
If yes, please explain
Claims Manager Information
Claims Manager
Claims Manager Email
Claims Manager Phone