Company Licensing Forms & Applications

Insurance Company Licenses

• Uniform Certificate of Authority Application [UCAA]

Reinsurers

• Reinsurer Application [pdf]

Auto Clubs or Associations

• Application for Certificate of Authority [CORE]
• Application for Auto Club Agent [pdf]
• Proof of Surety Bond [pdf]
• Appointment of Agent for Service of Process [pdf]
• Biographical Affidavit - Form 11 [UCAA]

Charitable Gift Annuities

• Charitable Gift Annuity Application Packet [CORE]
• Charitable Gift Annuity Issuer Annual Report Form [pdf]

Complex Rehabilitation Technology Suppliers

• Compliance Attestation Form [pdf]

County Mutual Insurance Companies

• County Mutual Annual Statement Instructions [pdf]
• County Mutual Annual Statement Form [Excel]

Discount Plan Operators

• Application for Discount Plan Operators [CORE]
  

Employee Leasing

• Employee Leasing Licensee Application [CORE]
• Employee Leasing Renewal Application [CORE]
• Guaranty Agreement Form [pdf]

External Review Organizations

• External Review Organizations Application Packet [pdf]
• External Review Disclosure Form [pdf]

Health Carrier Grievance Reporting Forms and Procedures

• Instructions and Packet [pdf]
• Instructions and Packet [Word]

MEWA

• MEWA Application [pdf]

Pharmacy Benefits Manager ("PBM") Licensing Packet

• Pharmacy Benefits Manager (PBM) Licensing Packet [CORE]
• Pharmacy Benefits Manager (PBM) Annual Report [pdf]

Prepaid Limited Health Service Organizations

• Prepaid Limited Health Service Organization Packet [pdf]

Preferred Provider Organizations

• Preferred Provider Organization Application [CORE]

Risk Purchasing Groups

• Application for Risk Purchasing Group [CORE]
• RPG Secretary's Certificate [pdf]
  
• RPG Service of Process Form [pdf]

Risk Retention Groups

• Application for Risk Retention Group [pdf]

Tax  Preparation Service Companies

• Tax Preparation Service Company Bond [pdf]

Third Party Administrators

• Life and Health Third-Party Administrators Packet [CORE]
• Workers Compensation Third-Party Administrators Packet [CORE]

Utilization Review Organizations

• Utilization Review Application Packet [pdf]

Vehicle Protection Product

• Warrantor's Initial Registration [pdf] (Vehicle Protection Act)
• Warrantor's Registration Renewal [pdf]

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