**version 20.09.30**

In order to use TPA Processing you MUST complete this enrollment webpage to become an active agent. Answer ALL questions listed below.

 Should you have questions please use the contact phone number (918) 245-1400.

Last Name:*

First Name:*

Zip Code:*
Social Security Number:* (###-##-####)

* Required entry

By electronically signing the below I acknowledge the following:

1. That TPA Processing will act as a Third Party Administrator (TPA) for any ALLOTMENT WORKSHEETS submitted by the above identified agent.
2. The above mentioned forms may be faxed, emailed, or mailed to TPA Processing.
3. I understand that I will have access to the TPA Processing Internet website in which I may set and modify certain aspects of my user profile. (www.tpaprocessing.com)
4. I understand that I have no formal affiliation with TPA Processing and will not be solicited to represent them.
5. I also authorize TPA Processing to distribute the amounts indicated on the client’s ALLOTMENT WORKSHEET.
6. I understand that any insurance coverage will only be effective upon the date of coverage stated on the respective policy(s) and after premium money has been collected and applied by the insurance carrier.
7. I further understand that if the employer fails to deduct the required payments, whether intentional, inadvertently or otherwise, TPA Processing shall have no liability whatsoever with respect thereto even though such failure may results in the forfeiture of any and all insurance commissions.
8. I must ensure all blocks of information are completed on the TPA Processing worksheet.
9. I will ensure my personal data is kept current on the TPA Processing website.
10. It is my personal responsibility to email, fax, or mail the appropriate TPA Processing worksheet to TPA Processing. Further, I understand I must ensure the TPA Processing worksheet is submitted as quickly as possible to TPA Processing.

NOTE: Enter your initials and the last 6 digits of your Social Security Number to signify your electronic signature.

(Example SD123456)

(aa ######)


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