Third Party Administrator
This is one of several pages linking to a central repository of forms used by TDI customers. Use the search or Forms by Type links on the Forms Home Page or scan through our form listings.
Premium Finance Forms | TDI Licensing Forms Main Page
Third Party Administrator Licensing Forms
TPA Application Forms | TPA Annual Report Forms
| TDI Form Number | Description | File Format | Language |
|---|---|---|---|
| FIN306 | Officers and Directors Page Complete Listing of all Current Officers and Directors - compliance with statutes |
English |
| TDI Form Number | Description | File Format | Language |
|---|---|---|---|
| FIN489 | Application for Certificate of Authority as an Administrator |
English | |
| FIN490 | Certification of Financial Statement |
English | |
| LHL081 | Administrator Biographical |
English | |
| LHL082 | Service of Process for Administrators |
English | |
| LHL177 | Licensing Checklist for TPA Name Change Checklist |
English | |
| LHL177 | TPA Name Change Checklist |
WORD | English |
| TDI Form Number | Description | File Format | Language |
|---|---|---|---|
| FastForm for electronic fingerprint appointment | FastPass Form for electronic fingerprint appointment Rev 3/2012 |
English | |
| FastForm for fingerprint card | Fingerprint Card Scan Authorization Form to submit with fingerprint card Rev 3/2012 |
English |
| TDI Form Number | Description | File Format | Language |
|---|---|---|---|
| FIN306 | Officers and Directors Page Complete Listing of all Current Officers and Directors - compliance with statutes |
English |
| TDI Form Number | Description | File Format | Language |
|---|---|---|---|
| FIN486 | Annual Report for Administrators |
English | |
| FIN487 | Annual Report for Insurers/HMOs |
English | |
| FIN488 | Annual Report Exhibits A-E |
EXCEL | |
| FIN490 | Certification of Financial Statement |
English | |
| LHL081 | Administrator Biographical |
English | |
| TPAFRMARINSTR | Instructions for FIN486 and FIN487 Instructions for filing the TPA Annual Report |
English |
| TDI Form Number | Description | File Format | Language |
|---|---|---|---|
| FastForm for electronic fingerprint appointment | FastPass Form for electronic fingerprint appointment Rev 3/2012 |
English | |
| FastForm for fingerprint card | Fingerprint Card Scan Authorization Form to submit with fingerprint card Rev 3/2012 |
English |
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