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Municipal Entity Underwriting Application

3.

When and what type of losses are referred out to another adjusting firm or an attorney?  

4.

Does the TPA have a separate unit to pursue subrogation?

Does the claims adjuster handle this function?

 Yes

 Yes

 No

 No

5.

What medical case management firms does the TPA use?

6.

Are all medical and hospital bills audited per the state fee schedule?

If no, please describe audit process.  

 Yes

 No

7.

How are bills audited?  

 In-house

Outside firm

8.

If outside firm, provide name of firm.

9.

Please provide the following information on the TPA.

a.

Proof Of E&O And Fidelity

b.

License To Act As A Third Party Administrator

c.

Confirmation Of Adjuster Licenses

d.

Organizational Chart With Resume Or Experience Level Of Associates

e.

In Place Written Reporting Requirements

f.

Reserving Policy

g.

Copy Of TPA Claim Policy, Service Standards And Procedures

h.

List Of Defense Counsels And Experts Used

i.

Copy of service agreement between TPA and entity containing detail on the TPA’s responsibility to excess carriers/reinsurers; confirming claims handling on a runoff basis; monthly quarterly, and annual reporting provisions; fund balance, reserving and payment provisions.

B.Systems Information

1.

Is TPA claim system

 Manual

 Automated

2.

Can claims report be generated on an “as needed” basis?  

 Yes

 No

3.

Do claims reports include

 Details On The Current Status Of Each Claim Paid Amount

Incurred Amount A Description Of The Type Of Loss

Does the system have the ability to track aggregate losses?

 Yes

 No

4.

Please provide the following sample reports.

a.

Individual Losses

b.

Captioned reports of specific losses

c.

Aggregate Tracking and aggregate loss fund (if applicable)

Loss and Historical Exposure Information

Please provide a summary of a minimum of six years (current year plus 5 historical years) of ground up losses (include copies of loss runs) for all desired lines of coverage.

Property

Loss Data Valued as of:

n/a

Year

Claims Processor (In-house, Insurance Co. Name, TPA Name)

TIV

Retained Limit

# Of Claims

Amounts Paid

Reserved

Total Incurred

Year:

Processor:

Year:

Processor:

Year:

Processor:

26 of 3410/23/2007

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