Form Si Tpa - Application For Third Party Administrator Permit Page 2
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A list of all Own Risk employers, Group Self Insurance associations, and other companies the applicant
provides services for.
l.
A copy of the applicant’s Errors and Omissions policy and fidelity bond.
9. In consideration of the approval of this application, the applicant hereby:
a.
Expressly agrees to comply with all applicable statutes, and with the Rules of the Workers’ Compensation
Commission; and
b. Certifies that the TPA:
1) Has adequate personnel on staff to handle the volume and type of work;
2) Establishes claims at the most likely outcome, rather than best case;
3) Retains independence when setting claim reserves; and
4) Maintains adequate computerized records and paper claims files on each claim.
Administrative Workers’ Compensation Act, 85A O.S., §6(A)(1)(a): “Any person or entity who makes any
material false statement or representation, who willfully and knowingly omits or conceals any material
information, or who employs any device, scheme, or artifice, or who aids and abets any person for the purpose
of: (1) obtaining any benefit or payment … shall be guilty of a felony.”
Any person who commits workers’ compensation fraud, upon conviction, shall be guilty of a felony punishable
by imprisonment, a fine or both.
I declare under penalty of perjury that I have examined this application and all statements contained herein, and to
the best of my knowledge and belief, they are true, correct and complete.
Signed this __________ day of _______________________________________, 20________.
_____________________________________________________________________________________________
Signature of Authorized Representative
(Note: Person signing should have authority to bind the applicant to the agreements contained herein)
_____________________________________________________________________________________________
Print Name of Authorized Representative
Title of Authorized Representative
_____________________________________________________________________________________________
Mailing Address
City
State
Zip Code
_____________________________________________________________________________________________
Street Address, if different from Mailing Address
City
State
Zip Code
_____________________________________________________________________________________________
E-mail Address of Authorized Representative
Telephone Number of Authorized Representative
Send application to:
OKLAHOMA WORKERS’ COMPENSATION COMMISSION
INSURANCE SERVICES DIVISION
1915 NORTH STILES AVENUE, SUITE 231
OKLAHOMA CITY, OK 73105
Form – SI TPA
Page 2 of 2
Rev. 09-21-15
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