TPA Processing DOES NOT provide loans.  If you are seeking a loan DO NOT complete this form.


Enter you name( Last, First)
Enter your current mailing address.
Enter your complete Social Security Number, with the dashes.
Enter your contact email.
Enter your cell number.

By signing the below I acknowledge the following:
1. That TPA Processing will act as a Third Party Administrator (TPA) for any ALLOTMENT WORKSHEETS submitted by the above identified agent.
2. The above mentioned forms may be faxed, emailed, or mailed to TPA Processing.
3. I understand that I will have access to the TPA Processing Internet website in which I may set and modify certain aspects of my user profile. (
4. I understand that I have no formal affiliation with TPA Processing and will not be solicited to represent them.
5. I also authorize TPA Processing to distribute the amounts indicated on the client’s ALLOTMENT WORKSHEET.
6. I understand that any insurance coverage will only be effective upon the date of coverage stated on the respective policy(s) and after premium money has been collected and applied by the insurance carrier.
7. I further understand that if the employer fails to deduct the required payments, whether intentional, inadvertently or otherwise, TPA Processing shall have no liability whatsoever with respect thereto even though such failure may results in the forfeiture of any and all insurance commissions.<br><br>

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