ࡱ> _ jbjbj bb'D...BBB8ztB*   )!*******$|,./l9*Q.$^ $$9**((($R8.*($*(((pY:$()*0*(/u%/((/.(D!G"h("T#!!!9*9*'!!!*$$$$/!!!!!!!!! :   1818 E. College Pkwy, Suite 103, Carson City, Nevada 89706 Phone: (775) 687-0700 Fax: (775) 687-0787 Web: doi.nv.gov  Third Party Administrators (TPA) CHECK LIST for use with the Annual Report as required by NRS 683A.08528. Report is due July 1 of each year. (Please Print or Type) Business Entity Name FEIN  Nevada TPA License Number Fiscal Year End FORMCHECKBOX Type (1) Life & Health  FORMCHECKBOX Type (2) Self-Funded Health Benefit Program  FORMCHECKBOX Type (3) Self-Funded Employer Program for Workers Compensation  FORMCHECKBOX Type (4) Workers Compensation Pursuant to NRS 683A.08528, each Third Party Administrator must file a report with the Commissioner. The report must include the information indicated below. Pursuant to NRS 683A.0892(1)(b)(8) and (e), the Commissioner may suspend or revoke the certificate of registration of the administrator and /or may impose a fine of $2,000 for each act or violation. NRS 683A.08528 1. Not later than July 1 of each year, each holder of a certificate of registration as an administrator shall file with the Commissioner an annual report for the most recently completed fiscal year of the administrator. Each annual report must be verified by at least two officers of the administrator. 2. Each annual report filed pursuant to this section must include all the following: (a) A financial statement of the administrator that has been reviewed by an independent certified public accountant. (b) The complete name and address of each person, if any, for whom the administrator agreed to act as an administrator during the most recently completed fiscal year of the administrator (c) Any other information required by the Commissioner. 3. In addition to the information required pursuant to subsection 2, if an annual report is prepared on a consolidated basis, the annual report must include a columnar or combining worksheet that: (a) Includes the amounts shown on the consolidated financial statement accompanying the annual report; (b) Separately sets forth the amounts for each entity included in the worksheet; and (c) Includes an explanation of each consolidating and eliminating entry included in the worksheet. 4. Each administrator who files an annual report pursuant to this section shall, at the time of filing the annual report, pay a filing fee in an amount determined by the Commissioner. . . . (Emphasis added)I am the contact person for the Third Party Administrator and on behalf of the administrator acknowledge that I understand that failure to provide the required annual report by July 1 of each year, may subject the administrator to suspension, revocation, and/or fines of $2,000 for each act or violation. Have you attached the officers verification, audited financials & client list?  FORMCHECKBOX  Yes If the financials are consolidated, does the report include a columnar or combining worksheet?  FORMCHECKBOX  Yes FORMCHECKBOX  N/A Have you attached the $25 filing fee made payable to the Nevada Division of Insurance?  FORMCHECKBOX  Yes Date: Signature: Contact persons Phone Number: Printed Name and Title of the person completing this Check List: Contact persons Fax Number:  This section for Division Use Only: Reviewed by:  FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       Date:  FORMTEXT       FORMTEXT       FORMTEXT       Was the report received timely?  FORMCHECKBOX  Yes  FORMCHECKBOX  No We e the financials audited?  FORMCHECKBOX  Yes  FORMCHECKBOX  No ** If not why not? FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       Was the client list attached and complete?  FORMCHECKBOX  Yes  FORMCHECKBOX  No Was the $25 filing fee provided?  FORMCHECKBOX  Yes  FORMCHECKBOX  No Was the report certified by two officers?  FORMCHECKBOX  Yes  FORMCHECKBOX  No Did the report comply with NRS 683A.08528?  FORMCHECKBOX  Yes  FORMCHECKBOX  No Was the TPA notified of deficiencies?  FORMCHECKBOX  Yes ** Please attach a copy of the notification. NAC 683A.119 Determination of whether the administrator or applicant is financially unsound. Additional review required. (1) Is the sum of the TPAs assets less than the sum of its liabilities?  FORMCHECKBOX  Yes  FORMCHECKBOX  No (2) Is there a recurring operating loss?  FORMCHECKBOX  Yes  FORMCHECKBOX  No (3) Is there a negative cash flow from operations?  FORMCHECKBOX  Yes  FORMCHECKBOX  No (4) Has there been a significant decrease in assets within a fiscal year or over a period of years?  FORMCHECKBOX  Yes  FORMCHECKBOX  No Reviewed by:  FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       Date:  FORMTEXT       FORMTEXT       FORMTEXT       Comments:________________________________________________________________________________________________ho  5 6 7 O S T U i ɴɴɴɤykZVRVKD hChhI hChx]hy76hhI h7DhhI>*B*CJ aJ phhhI>*B*CJ aJ ph h82hW >*B*CJaJph h82hhI>*B*CJaJphhO&dh82aJjh82UaJmHnHu(h825CJOJQJ\^JaJmH sH "h82CJOJQJ^JaJmH sH h82h82h82>*B*ph&jh82>*B*UmHnHphu7 8 T i p $dh$If^gd=  z @$Ifgd]2 $$ da$gdhI$a$gdhI x1$gd82gd82gdhI i j q r s t   , - . 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