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
ZIP
County
Country

Claims Handling Office That Will Be Assigned to the Client

Address
City
State
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