INSTRUCTIONS: CONNECTICUT UNIFORM APPLICATION FOR THIRD PARTY ADMINISTRATOR LICENSE

To apply for a third party administrator license in Connecticut, use the form discussed in this article. This document can be obtained from the website of the government of Connecticut.

Connecticut Uniform Application For Third Party Administrator License Step 1: Check the box where indicated if this is a new application.

Connecticut Uniform Application For Third Party Administrator License Step 2: Enter the applicant name in box 1.

Connecticut Uniform Application For Third Party Administrator License Step 3: Enter the incorporation or formation date in box 2.

Connecticut Uniform Application For Third Party Administrator License Step 4: Enter the federal employer identification number in box 3.

Connecticut Uniform Application For Third Party Administrator License Step 5: Enter your company trade or "doing business as" name in box 4.

Connecticut Uniform Application For Third Party Administrator License Step 6: Enter your state of domicile in box 5 and your country of domicile in box 6.

Connecticut Uniform Application For Third Party Administrator License Step 7: Enter your business address in box 7, your city in box 8, your state in box 9, and your zip code in box 10.

Connecticut Uniform Application For Third Party Administrator License Step 8: Enter your business phone number in box 11 and your fax number in box 12.

Connecticut Uniform Application For Third Party Administrator License Step 9: Enter your business web site address in box 13 and your business email address in box 14.

Connecticut Uniform Application For Third Party Administrator License Step 10: Enter your business mailing address in box 15, your p.o. box number (if applicable) in box 16, your city in box 17, your state in box 18, and your zip code or foreign country in box 19.

Connecticut Uniform Application For Third Party Administrator License Step 11: List all owners, officers, partners and directors where indicated, along with their titles, Social Security number or federal employer identification number, and their percentage of ownership.

Connecticut Uniform Application For Third Party Administrator License Step 12: Note all resident and non-resident jurisdictions to which you are applying on the second page.

Connecticut Uniform Application For Third Party Administrator License Step 13: Answer questions 1 through 6 concerning background information as instructed. Sign and date the form on the third page where indicated.

INSTRUCTIONS: ALABAMA ARCHIVAL RECORDS TRANSMITTAL FORM 

To document the transmittal of Alabama archival records to the state Department of Archives and History, use the form discussed in this article. This document can be obtained from the website maintained by the Alabama Department of Archives and History.

Alabama Archival Records Transmittal Form Step 1: Enter your agency name on the first blank line.

Alabama Archival Records Transmittal Form Step 2: Enter your division or office on the second blank line.

Alabama Archival Records Transmittal Form Step 3: Enter your mailing address on the third blank line.

Alabama Archival Records Transmittal Form Step 4: Enter the authorized agency transferring agent on the fourth blank line.

Alabama Archival Records Transmittal Form Step 5: Enter the transferring agent's telephone number on the fifth blank line.

Alabama Archival Records Transmittal Form Step 6: Enter the archival records title on the sixth blank line.

Alabama Archival Records Transmittal Form Step 7: Enter the year span of the records on the seventh blank line.

Alabama Archival Records Transmittal Form Step 8: Indicate whether the records are arranged alphabetically, chronologically, numerically, or are not arranged with a check mark.

Alabama Archival Records Transmittal Form Step 9: Indicate whether there is a restriction of access with a check mark. If yes, state the reason.

Alabama Archival Records Transmittal Form Step 10: On the next blank line, enter the type and number of the hardware device containing the records.

Alabama Archival Records Transmittal Form Step 11: On the next blank line, enter the device's total number of bytes.

Alabama Archival Records Transmittal Form Step 12: On the next blank line, enter the application and version of software used to create the records.

Alabama Archival Records Transmittal Form Step 13: On the next blank line, enter the file format and extension.

Alabama Archival Records Transmittal Form Step 14: On next blank line, enter the metadata level.

Alabama Archival Records Transmittal Form Step 15: On the next blank line, enter the signature of the authorized agency transferring agent.

Alabama Archival Records Transmittal Form Step 16: On the next blank line, enter the date.

Alabama Archival Records Transmittal Form Step 17: On the next blank line, enter the the signature of a staff member for quality control review. Enter the date on the next blank line.

INSTRUCTIONS: CONNECTICUT UTILIZATION REVIEW LICENSE APPLICATION

To prepare an application for a Connecticut license to conduct a utilization review, use the form discussed in this article. This document can be obtained from the website maintained by the government of Connecticut.

Connecticut Utilization Review License Application Step 1: Enter the name of your company on the first blank line.

Connecticut Utilization Review License Application Step 2: Enter the address of your company on the next two blank lines.

Connecticut Utilization Review License Application Step 3: Enter the telephone number of your company on the next blank line.

Connecticut Utilization Review License Application Step 4: Enter the toll free telephone number of your company on the next blank line.

Connecticut Utilization Review License Application Step 5: Enter your business hours on the next blank line. The times should be entered in east coast time.

Connecticut Utilization Review License Application Step 6: Enter the name of a contact person on the next blank line.

Connecticut Utilization Review License Application Step 7: Enter the direct telephone number for your contact person on the next blank line.

Connecticut Utilization Review License Application Step 8: Enter the email address of your contact person on the next blank line.

Connecticut Utilization Review License Application Step 9: The remainder of the first page and the next two pages have instructions for applying for a utilization review license.

Connecticut Utilization Review License Application Step 10: Print your name on the first blank line of the fourth page.

Connecticut Utilization Review License Application Step 11: Enter your title on the second blank line.

Connecticut Utilization Review License Application Step 12: Enter the name of your company on the third blank line.

Connecticut Utilization Review License Application Step 13: Enter your signature on the fourth blank line.

Connecticut Utilization Review License Application Step 14: Enter the date on the fifth blank line.

Connecticut Utilization Review License Application Step 15: The last three pages contain a utilization review survey. Enter the name of your company, your tax identification or federal employer identification number and provide all requested information about the person completing the survey at the top of the fifth page.

Connecticut Utilization Review License Application Step 16: Answer questions 1 through 7 on the fifth page as directed, then answer questions 8 through 16 on the second page and question 17 on the third page.