Application – PlanSURITY

TPA Application

Name of Third Party Administrator (TPA)

Address

Address 2

Zip

City

State

Years in Business

Covered Lives (All Products)

Who is authorized to sign an agreement with us on behalf of your TPA?

Contact First Name

Contact Last Name

Work Phone

Mobile Phone

Website (if applicable)

Please select one of the following:

Dental

Health

Other

How large is your dental book of business (covered lives)?

Please select one of the following:

Brokered Individual

Small & Medium-Sized Business (Less than X lives)

Corporate (Greater than X lives)

Institutional (e.g. School Boards, Government)

Unions

Average Client Size

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