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This version of the form is not currently in use and is provided for reference only. Download this version of
Form FIS0862
for the current year.
Form FIS0862 Third Party Administrator (Tpa) Affiliation Statement - Michigan
What Is Form FIS0862?
This is a legal form that was released by the Michigan Department of Insurance and Financial Services - a government authority operating within Michigan. As of today, no separate filing guidelines for the form are provided by the issuing department.
FAQ
Q: What is Form FIS0862?
A: Form FIS0862 is the Third Party Administrator (TPA) Affiliation Statement.
Q: What is a Third Party Administrator (TPA)?
A: A Third Party Administrator (TPA) is an organization that administers employee benefit plans on behalf of employers.
Q: Why is the TPA Affiliation Statement required?
A: The TPA Affiliation Statement is required to disclose any affiliations or relationships that the TPA may have with various entities.
Q: Who needs to submit Form FIS0862?
A: TPAs operating in the state of Michigan need to submit Form FIS0862.
Q: Are there any fees associated with submitting Form FIS0862?
A: There are no fees associated with submitting Form FIS0862.
Q: What information is required on Form FIS0862?
A: Form FIS0862 requires the TPA to disclose information such as their name, address, contact details, and any affiliations or relationships.
Q: What is the deadline for submitting Form FIS0862?
A: The deadline for submitting Form FIS0862 is typically specified by the Michigan Department of Insurance and Financial Services.
Q: Are there any penalties for not submitting Form FIS0862?
A: Failure to submit Form FIS0862 may result in penalties imposed by the Michigan Department of Insurance and Financial Services.
Q: Can TPAs from other states submit Form FIS0862?
A: No, Form FIS0862 is specific to TPAs operating in the state of Michigan and is not required for TPAs from other states.
Form Details:
- Released on May 1, 2015;
- The latest edition provided by the Michigan Department of Insurance and Financial Services;
- Easy to use and ready to print;
- Quick to customize;
- Compatible with most PDF-viewing applications;
- Fill out the form in our online filing application.
Download a fillable version of Form FIS0862 by clicking the link below or browse more documents and templates provided by the Michigan Department of Insurance and Financial Services.
Download Form FIS0862 Third Party Administrator (Tpa) Affiliation Statement - Michigan
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