Alphabetical List
| Title |
Form # |
| Affidavit for Lost Certificate of Authority |
2361
Word | PDF |
| Amended
Certificate of Authority Application |
|
| Application for Reservation of Name |
Word | PDF |
| |
| Certificate of Authority Application |
| Domestic
Home Protection |
|
| Domestic
Insurer |
|
| Foreign
or Alien Home Protection Insurer |
|
| Health
Care Service Contractor (HCSC) |
|
| Insurance
Companies |
|
|
|
|
| Health Care Service Contractor Bond |
3117
Word |
PDF |
| Home Protection Insurer Bond |
2805
Word | PDF |
| Organizational Bond |
3094
Word | PDF |
| Permit to Organize Insurer with or without Capital Stock
Application |
3106
Word |
PDF |
| |
| Change of Registered Office and Registered Agent by
Insurer |
3310
Word | PDF |
| Instructions |
| Designation of Registered Office and Registered Agent
by Insurer |
3309
Word |
PDF |
| External Review Referral Request |
3430
Word |
PDF |
| External Review Annual Summary |
3639
Word |
PDF |
| |
| Forms A through D |
| Statement Regarding the Acquisition of Control of Merger
with a Domestic Insurer |
Form
A |
| Insurance Holding Company System Annual Registration |
Form
B |
| Summary of Registration Statement |
Form
C |
| Prior Notice of a Transaction |
Form
D |
| |
| Form I.S.S. and instructions |
2035
Word |
PDF |
| Form C.S.S. and instructions |
2036
Word |
PDF |
| Health
Benefit Plan Report |
|
| Instructions |
| Quarterly Health Enrollment Report |
|
| Instructions |
| |
| Legal Expense Organization |
| Certificate of Registration |
2167
Word |
PDF |
| Instructions |
| Change of Registered Office or Registered Agent |
2169
Word |
PDF |
| Designation of Registered Office or Registered Agent |
2168
Word |
PDF |
| Financial Statement |
2164
Word |
PDF |
| Legal Expense Insurance List of Sales & Marketing
Representatives |
2166
Word |
PDF
|
| Qualifying Bond for Legal Expense |
2165
Word |
PDF |
| Renewal of Certificate of Registration for Legal Expense
Organization Application |
2170
Word |
PDF |
| |
| Life Settlement Provider |
| Application for License as Life Settlement Provider |
3015
Word |
PDF |
Form
Filing Information |
|
| Life Settlement Broker Appointment/Affiliation Notice |
3025
Word |
PDF |
| Life Settlement Provider Annual Statement |
4882
Word |
PDF |
| Life Settlement Provider, Appointment of Insurance Commissioner
for Legal Service |
4880
Word |
PDF |
| Life Settlement Provider Bond |
3359
Word |
PDF |
| |
| Medical/Dental Negligence Claim Report |
1962 |
| |
| Medical Discount Plan Organizations |
| Discount Medical Plan Organization Application |
4782
Word |
PDF |
| Discount Medical Plan Organization Renewal |
4793
Word |
PDF |
| Appointment of Insurance Commissioner for Legal Service |
4779
Word |
PDF |
| |
| Multiple Employer Welfare Arrangement |
| Certificate of Multiple Employer Welfare Arrangement
Application |
3132
Word |
PDF |
| Multiple Employer Welfare Arrangement Bond |
3630
Word |
PDF |
| |
| Obligors |
| Obligor of Home Service Agreement Bond |
3443
Word |
PDF |
| Obligor of Service Contracts Registration Application |
2851
Word |
PDF |
| |
| Patient Protection Reporting Forms |
| Grievance Annual Report |
3241
Word |
PDF |
| Quality Assessment Annual Summary |
3239
Word |
PDF |
| Network Adequacy Annual Summary |
3237
Word |
PDF |
| Utilization Review Annual Summary |
3238
Word |
PDF |
| |
Prompt Payment Data Report
For health insurers and health care service contractors |
3431
Word |
PDF |
| Instructions |
| Provider Network Contract Annual Registration |
1084
Word |
PDF
|
| |
| Rating Organizations |
| Rating Organization License Application |
3246
Word |
PDF |
| Rating Organization Amended License Application |
3247
Word |
PDF |
| |
| Retainer Medical Practice Application |
2278
Word |
PDF |
| Retainer Medical Practice Renewal Application |
2978
Word |
PDF |
| Retainer Medical Practice Biographical Affidavit |
2279
Word |
PDF |
| |
| Risk Retention Groups |
| Registration as a Purchasing Group |
3663
Word |
PDF |
| Instructions for Risk Purchasing Group Application Form |
3664
Word |
PDF |
| Registration as a Liability Risk Retention Group (Foreign) |
3665
Word |
PDF |
| Instructions for Liability Risk Retention Group Application
Form |
3666
Word |
PDF |
| Appointment of Attorney to Accept Service |
3023
Word |
PDF |
| |
| Security Deposit |
| Security Deposit Release General Request |
3461
Word |
PDF |
| Security Deposit Release Request For Workers' Compensation |
2944
Word |
PDF |
| |
| Tax Forms |
| Excise |
|
Insurance
Amended Tax Return
(Filed through the iReg reporting system) |
|
| Ocean Marine |
PDF |
Excel |
Insurance
Tax Return
(Filed through the iReg reporting system) |
|
Retaliatory Tax Calculation
for Non-Domestic Legal Expense Organizations |
4879
PDF |
Excel |
Risk Retention Tax
(Filed through the iReg reporting system) |
|
| Surplus Lines Licensee Affidavit for Purchasing Groups |
3928
Word |
PDF |
| |
| Vehicle Theft Protection |
| Warrantor of Vehicle Protection Product Registration
Application |
4778
Word |
PDF |
| |
