OKLAHOMA WORKERS’ COMPENSATION COMMISSION
1915 NORTH STILES AVENUE
OKLAHOMA CITY, OK 73105
(405) 522-3222 or In-State Toll Free (855) 291-3612
APPLICATION FOR THIRD PARTY ADMINISTRATOR PERMIT
Date__________________________________
The undersigned, a company providing Third-Party Administrative Services to Own Risk employers and/or Group
Self-Insurance Associations, hereby applies for permission to act as an approved Third-Party Administrator. To
enable the Workers' Compensation Commission to determine the applicant’s ability to provide these services, said
applicant hereby states the following:
1. TPA Name ________________________________________________________________________________
2. Desired effective date (application should be submitted 30 days in advance) ___________________________
3. TPA # (if a renewal applicant) _________________________________________________________________
4. Name of Parent Company, if applicable _________________________________________________________
5. Home office address, phone number & e-mail address _____________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
6. Oklahoma office address, phone number & e-mail address __________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
7.
Years in business: Nationally _______________________ In Oklahoma _______________________________
8. Please include the following items with the application:
a.
A nonrefundable $1,000 application fee, payable to the Oklahoma Workers’ Compensation Commission.
b. Audited financial statements for the most recent fiscal year, including a balance sheet, statement of
income, statement of cash flows, and notes. Financial statements may be submitted via email to
InsuranceDepartment@wcc.ok.gov
or via a cd delivered with the application.
c.
A list of all claims adjusters on staff. Please include a photocopy of the current Oklahoma license for each
adjuster.
d. A list of all claims managers or equivalent supervisory personnel. Please include a brief resume for each
manager.
e.
A description of how service fees are determined.
f.
Services performed by the applicant. If services are provided other than claims adjusting, such as safety
consulting, marketing or accounting functions, please provide a brief resume of the principal employee(s)
providing these services.
g.
A description of how client funds are handled for payment of claims.
h. A copy of the most recent triennial independent audit performed on the applicant.
i.
A copy of the Service Organization Controls (SOC) 1 report pursuant to the statement on standards for
attestation engagements (SSAE) No. 16, resulting from the most recent independent audit.
j.
A description of the applicant’s policy for setting reserves.
Form – SI TPA
Page 1 of 2
Rev. 09-21-15