Insurance TPA Form

INSURANCE TPA AUTHORIZATION AND INFORMATION FORM

Applicant / Insured Information

Phone:    Email:

Date of Birth (if individual):    Employer / Plan Sponsor:

Policy Details

Policy Number:    Policy Type: Health Disability Property Liability Workers' Comp

Coverage Amount: $    Deductible: $    Premium: $

Policy Period From:    To:

Authorized TPA Information

Contact Person:    Phone:    Email:

TPA Authorization Effective Date:

Scope of Services — Select Services to Be Performed by TPA

The Applicant hereby authorizes the TPA to perform the following services as agent of the Applicant or Plan Sponsor within the limits set forth in this form and any separate written delegation agreement. Check each service to be authorized:

Claims Reporting (if applicable)

Date of Loss:    Claim Type:

Estimated Incurred Amount: $

Documentation Checklist

Please indicate which documents accompany this submission:

Exclusions, Limitations, and Delegation Terms

The Applicant acknowledges and agrees that the TPA's authority is limited to the scope selected above and any separate written delegation agreement. The TPA will act as agent of the Applicant or Plan Sponsor only to the extent authorized in writing. The TPA shall not be responsible for: (a) establishing policy limits; (b) underwriting decisions; or (c) payment of premiums unless separately agreed in writing.

Exclusions (check any that apply to limit TPA authority):

Indemnification and Limitation of Liability: The Applicant agrees to indemnify, defend and hold harmless the TPA, its directors, officers, employees and agents from and against any and all claims, liabilities, costs and expenses arising from the performance of services under this authorization, except to the extent resulting from the TPA's gross negligence or willful misconduct. The TPA’s liability for any negligence shall be limited to direct damages and shall not include consequential, special, punitive or incidental damages.

Subcontractors: TPA may engage subcontractors or vendors to perform services, provided TPA remains responsible for performance under this authorization. Confidential information provided to subcontractors shall be subject to confidentiality obligations consistent with this authorization.

Term and Termination: This authorization shall remain in effect until revoked in writing by the Applicant or Plan Sponsor. Revocation will not affect actions taken by the TPA prior to receipt of written revocation.

Beneficiary / Payee Designation (if applicable)

Designate beneficiary(ies) for claim proceeds or recoveries associated with this policy or plan. Provide percentages that sum to 100%.

Relationship:    Percentage: %

Relationship:    Percentage: %

Certification and Authorization

By signing below, the Applicant certifies that the information provided on this form is true, complete and correct to the best of the Applicant's knowledge. The Applicant authorizes the TPA to: (a) obtain and review records and information necessary to administer claims and services described above, including medical, employment and financial records; (b) exchange information with insurers, providers, employers, other administrators, and relevant third parties; and (c) take actions reasonably necessary to investigate, evaluate, settle or otherwise process claims, subject to the limits and exclusions specified in this form.

The Applicant acknowledges any protected health information (PHI) disclosed to the TPA will be used and disclosed in accordance with applicable privacy laws, and hereby authorizes the release of PHI to the TPA for the purposes of claims administration and benefit management.

The Applicant further agrees to cooperate with reasonable requests by the TPA for documentation, authorizations, and other assistance necessary for the performance of TPA services. This authorization is intended to create contractual authority for the TPA to act on behalf of the Applicant or Plan Sponsor within the scope granted herein.

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