Third-Party Administrator Attestation: Exception for Certificate of Registration Requirement Exception from Registration Requirement Form Under Iowa Code section 510.21, a person is required to hold a certificate of registration to act as a third-party administrator in the State of Iowa. Iowa Administrative Code rule 191-58.3 allows exceptions to this requirement. To claim an exception, check the applicable exception reason below. You will also need to print, complete and have this affidavit page notarized. Once completed, upload it with this form submission. Affiant Information First Name * date_range access_time Last Name * date_range access_time Administrator Information Business Name * date_range access_time FEIN * date_range access_time Address * date_range access_time City * date_range access_time State * Please select an option Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip Code * Ex. 55555-5555 date_range access_time Contact Information First Name * date_range access_time Last Name * date_range access_time Phone Number * Ex. 555-555-5555 date_range access_time Fax Number Ex. 555-555-5555 date_range access_time Email * date_range access_time Exception Reason Select the Exception for Certificate of Registration * 1. The only action being performed is as an employer administering its employee benefit plan or the plan of an affiliated employer under common management and control. 2. The only action being performed is as a trust exempt from taxation under Section 507(a) of the Internal Revenue Code and its trustees and employees acting pursuant to such trust, or a custodian and the custodian’s agents or employees acting pursuant to a custodian account that meets the requirements of Section 401(f) of the Internal Revenue Code. 3. The only action being performed is as a person licensed as a managing general agent in this state when acting within the scope of activities conveyed under such a license. 4. The administrator is an insurer that underwrites, collects charges, collateral or premiums from, or adjusts or settles claims for no one other than its policyholders, subscribers and certificate holders. 5. The third-party administrator is affiliated with a licensed insurer and only acts as a third-party administrator for the direct and assumed insurance business of the affiliated insurer. 6. A person only acts as a third-party administrator for a group plan based in another state that has fewer than 100 insureds under the plan residing in Iowa. 7. A person who directly or indirectly underwrites, collects charges or premiums from, or adjusts or settles claims on residents of this state, only in connection with life, annuity or health coverage provided by a self-funded plan other than a governmental or church plan.** 8. An administrator operating solely as a single-employer trust or Taft-Hartley labor union trust as defined under ERISA. Please be aware that claiming an exception does not relieve the entity of other applicable requirements under Iowa law.**Please note that if the entity or person manages the prescription drug benefit provided by a third-party payor, the entity is defined as a Pharmacy Benefit Manager under Iowa Code 510B and required to register as a Third-Party Administrator pursuant to Iowa Code 510B.2. navigate_nextContinue Your Session Is About To Expire Click continue to extend your session. Your Session Has Expired Close your browser or click OK to begin a new session.
