Third Party Administrator Application Procedure

Complete and submit the following forms to the Department of Insurance and Financial Services (DIFS). These forms comprise the entire application package:

• FIS 0849  Application Checklist to ensure all required materials are submitted
• FIS 0850  Financial Statement
• FIS 0860  Consent to Service for entities domiciled in states other than Michigan
• FIS 0861  Application for Certificate of Authority
• FIS 0862  Affiliation Statement for all officers, directors, and stockholders of 10% or more stock
• FIS 0863  Fee Processing Card

Financial Viability

In lieu of submitting Pages 2 and 3 the FIS 0850 Financial Statement, an audited financial statement for the period ending closest to the date of application may be submitted. The audited financial statement must be accompanied by Page 1 of the FIS 0850. Audited financial statements of an applicant TPA's parent company are not relevant and will not be accepted.

A TPA will be considered financially viable under MCL 550.912(1)(e) if one of the following conditions is met:

• It received an unqualified opinion from an independent public accountant showing it is solvent based upon generally accepted accounting principles, or
• It remains solvent after adjusting for goodwill and intangible assets if no independent public accountant opinion is obtained.

In the event an applicant or certified TPA does not meet either of these criteria, they must submit other legitimate proof of financial viability to DIFS staff.