* Required entry
electronically signing the below I acknowledge the
1. That TPA Processing
will act as a Third Party Administrator (TPA) for any
ALLOTMENT WORKSHEETS submitted by the above identified
2. The above mentioned forms may be faxed, emailed, or mailed to
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.
4. I understand that I have no formal
affiliation with TPA Processing and will not be solicited to
5. I also authorize TPA Processing to
distribute the amounts indicated on the client’s ALLOTMENT
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.
Enter your initials and the last 6 digits of your Social
Security Number to signify your electronic signature.