Fillable Printable Voluntary Plan Third Party Administrator Administrative Changes (De 2520Bv-B)

Voluntary Plan Third Party Administrator Administrative Changes (De 2520Bv-B)

VOLUNTARY PLAN THIRD PARTY ADMINISTRATOR

ADMINISTRATIVE CHANGES

Employer Name: Voluntary Plan Number:

California Employer Account Number:

1. Primary TPA contact:

Name: Title:

Address: Phone:

Fax: Email:

Duties performed: A B C D E F G H I J

(Check applicable box(es) above; see legend below for duty description.)

2. Secondary TPA contact information and duties performed:

Name: Title:

Address: Phone:

Fax: Email:

Duties performed: A B C D E F G H I J

(Check applicable box(es) above; see legend below for duty description.)

3. Additional TPA contact information and duties performed:

Name: Title:

Address: Phone:

Fax: Email:

Duties performed: A B C D E F G H I J

(Check applicable box(es) above; see legend below for duty description.)

Duties performed legend:

A. Annual Report of Self-Insured VP Transactions (DE 2568V)

B. New plan text and/or statement of Coverage

C. Plan text amendments

D. Security reviews

E. Financial audits

F. Claims audits

G. Withdrawn plans

H. VP administrative change updates

I. All forms related to claims processing

J. All of the above

4. To be completed by the TPAs authorized representative:

Print Name: Title:

Signature: Date:

Phone: Email:

DE 2520BV-B (8-17) (INTERNET) Page 1 of 2 CU

Please provide pre-authorized Third Party Administrator (TPA) contact information.

Attachment B

DE 2520BV-B (8-17) (INTERNET) Page 2 of 2

VOLUNTARY PLAN

THIRD PARTY ADMINISTRATOR ADMINISTRATIVE CHANGES FORM

INSTRUCTIONS

1. Enter the primary Third Party Administrator (TPA) contact information and duties performed.

2. Enter the secondary contact information and duties performed.

3. Enter the additional contact information and duties performed.

4. Enter the requested information of the TPAs authorized representative completing this form.

Send the form to the Employment Development Department by using one of the delivery methods listed below.

Mailing Address:

EDD, Disability Insurance Branch

Voluntary Plan Group

Attention: Database Administrator

PO Box 826880, MIC 29VP

Sacramento, CA 94280-0001

Email Address:

VPProgr[email protected]

Fax:

916-319-1438