INSTRUCTIONS: CONNECTICUT UNIFORM APPLICATION FOR THIRD PARTY ADMINISTRATOR LICENSE

To apply for a third party administrator license in Connecticut, use the form discussed in this article. This document can be obtained from the website of the government of Connecticut.

Connecticut Uniform Application For Third Party Administrator License Step 1: Check the box where indicated if this is a new application.

Connecticut Uniform Application For Third Party Administrator License Step 2: Enter the applicant name in box 1.

Connecticut Uniform Application For Third Party Administrator License Step 3: Enter the incorporation or formation date in box 2.

Connecticut Uniform Application For Third Party Administrator License Step 4: Enter the federal employer identification number in box 3.

Connecticut Uniform Application For Third Party Administrator License Step 5: Enter your company trade or "doing business as" name in box 4.

Connecticut Uniform Application For Third Party Administrator License Step 6: Enter your state of domicile in box 5 and your country of domicile in box 6.

Connecticut Uniform Application For Third Party Administrator License Step 7: Enter your business address in box 7, your city in box 8, your state in box 9, and your zip code in box 10.

Connecticut Uniform Application For Third Party Administrator License Step 8: Enter your business phone number in box 11 and your fax number in box 12.

Connecticut Uniform Application For Third Party Administrator License Step 9: Enter your business web site address in box 13 and your business email address in box 14.

Connecticut Uniform Application For Third Party Administrator License Step 10: Enter your business mailing address in box 15, your p.o. box number (if applicable) in box 16, your city in box 17, your state in box 18, and your zip code or foreign country in box 19.

Connecticut Uniform Application For Third Party Administrator License Step 11: List all owners, officers, partners and directors where indicated, along with their titles, Social Security number or federal employer identification number, and their percentage of ownership.

Connecticut Uniform Application For Third Party Administrator License Step 12: Note all resident and non-resident jurisdictions to which you are applying on the second page.

Connecticut Uniform Application For Third Party Administrator License Step 13: Answer questions 1 through 6 concerning background information as instructed. Sign and date the form on the third page where indicated.