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Amendments to the TPA
DIFS staff should be notified in writing within 30 days of any of the following changes to the TPA:
- Change of name. Report by submitting an FIS 0865 Third Party Administrator Jurat Page for Annual Renewal, and include amended articles of incorporation or other applicable documents. A new TPA Certificate of Authority will be created automatically if a name change occurs.
- Adoption of an assumed name/dba. Report the assumed name/dba information by submitting an FIS 0865 Third Party Administrator Jurat Page for Annual Renewal, accompanied by a true copy of the dba filing.
- Change in articles of incorporation or bylaws: Report by submitting a true copy of the amended articles of incorporation or bylaws.
- Change of the corporate entity or Federal Employer Identification Number (FEIN). Change of the corporate entity, such as a merger or re-incorporation, is deemed to be significant. If new officers, directors, or stockholders of 10% or more result from a merger, each new individual or entity must complete an FIS 0862 Third Party Administrator Affiliation Statement. A change of FEIN requires a new application and fees for the new entity.
- Change of business address/mailing address. Report by submitting an FIS 0865 Third Party Administrator Jurat Page for Annual Renewal.
- Change in officers, directors, or shareholders holding 10% or more of the TPA's stock. An FIS 0862 Third Party Administrator Affiliation Statement will be required if one has not already been filed for the individual(s) or entities. For changes in officer titles, or resignations of officers, directors, or stockholders, inform DIFS Insurance Licensing staff in writing. For changes in ownership, provide verification of the ownership change with stock certificates, ownership agreements, etc.
- Change of person or address designated to receive service of process. Report by submitting an FIS 0860 Third Party Administrator Consent to Service.
- Change in status of the business. For example, if you are going to cease acting as a TPA, inform DIFS Insurance Licensing staff in writing.