Get Service Contract Provider Registration Form

Filling out the Service Contract Provider Registration Form online can streamline the process of ensuring compliance with regulations set forth by the Arkansas Insurance Department. This guide provides clear, step-by-step instructions to help users complete the form effectively and efficiently.

Follow the steps to complete the registration form online.

1. Press the ‘Get Form’ button to access the registration form and open it in your chosen online editor.
2. In the Registration Information section, indicate whether this is a renewal form, and include the $200 registration fee. Ensure that your check is made payable to the State Insurance Department Trust Fund.
3. Provide the Provider Identification Information. Fill in the legal name of the provider, any trade name if applicable, and the principal business street address, including city, state, and zip code. Include the contact person's name, email address, telephone number, and facsimile number.
4. Specify the domicile of the provider in the designated field.
5. If your contact person differs from the representative handling inquiries about service contracts sold in Arkansas, provide that representative's name, email address, principal business street address, city, state, zip code, telephone, and facsimile numbers.
6. List the states where your provider is actively engaged in providing service contracts.
7. Answer the question regarding any administrative or regulatory actions taken against the provider in the past ten years. If applicable, attach a detailed explanation.
8. Submit a copy of the provider’s most recent financial statements, including the balance sheet and income statement, certified by a company officer.
9. In the Compliance with Financial Requirements section, indicate which compliance option is chosen and provide the necessary details and documentation, such as insurance policy copies or financial statements as required.
10. Complete the Provider Certification section by signing, printing your name, and dating the form.
11. Have the form notarized and complete the notary information section.
12. After verifying all information is accurate and complete, save your changes, then download, print, or share the completed registration form as needed.

Start the process of documenting your services by completing the form online today.