Department of Business and Industry Nevada Division of ...
Department of Business and Industry
Nevada Division of Insurance
Nevada Application for Third-Party Administrators
(Please Print or Type)
Entity Name
Fiscal Year End (dd/mm)
FEIN
DBA/Trade Name (if applicable)
State of Domicile
Qualification Type(s):
Life & Health Self-Funded Employer Program for Workers' Compensation Pharmacy Benefits Manager
Self-Funded Health Benefit Program Workers' Compensation
Are you applying for a Resident or Non-Resident License?
Resident
Non-Resident
Mailing Address
If Non-Resident, indicate Resident State
City
State
Zip or Foreign Country
Physical Business Address
City
State
Zip or Foreign Country
TPA Contact Person
List the primary contact person with whom the Division should communicate with after the completion of the certification.
Name
Title
Direct Telephone Number
Email Address
Mailing Address (if different than applicant's mailing address)
City
State
Zip Code
Ownership
Identify the owner(s) or parent(s) of the applicant. (Individuals who are owners should be listed on the following page.)
Corporation
Limited Liability Company
Other
Name
1.
2.
Percentage of Ownership
%
%
TPA 1003 rev. 7.2019
Owners, Partners, Officers & Directors
List all sole proprietor or partners, officers and directors of the applicant. (List only those owners with 10% or more ownership.) An NAIC biographical affidavit is required for each person listed.
Name
1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20.
Title
Must be signed by an officer, director, principal or partner of the applicant:
Month
Day
Year
Percentage of Ownership
% % % % % % % % % % % % % % % % % % % %
Signature
Typed or Printed Name
Title
Address
City
State
Zip
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