Forms

  • Forms that are marked with a Y in the Fill column can be completed on-line through Adobe Acrobat Reader.
  • Users with Adobe 6.0 and above will need to change a setting before completing the forms so that the tabbing order works correctly. Open Adobe Acrobat, go to the tab on top labeled Edit, go to Preferences, and Accessibility. Make sure the box Use document structure for tab order when no explicit tab order is specified is not checked.
  • Dates must be entered in the following format: mm/dd/yyyy.
  • When printing a form from Adobe Acrobat, the Page Scaling needs to be set to None. This can be found under File, Print, Page Handling Section. There will be a section called Page Scaling with drop down options. Please select None from those options. If any of the other options are selected, additional white space will be added to the margins of the form and the form will shrink.

Insurance Department - Public Form(s)

SFNTitleSizeDateFillable
3380 COVERAGE CHANGES ON CURRENT PROPERTY INS 181 kb 01/13/2012 Y
4792 DATA PROCESSING QUESTIONNAIRE 39 kb Y
4795 AFFIDAVIT 167 kb Y
4805 COUNTY MUTUAL ABSTRACT OF STATEMENT 157 kb 11/26/2012 Y
4818 SURPLUS LINES AFFIDAVIT 328 kb 06/28/2012 Y
4824 SURPLUS LINES ANNUAL PLACEMENT REPORT 677 kb 12/08/2015 Y
7832 FIRE INSURANCE PREMIUMS AND LOSSES 231 kb Y
8330 AGENT FOR SERVICE OF PROCESS 205 kb 01/12/2009 Y
9576 NOTICE OF LOSS 274 kb 01/20/2012 Y
10706 BOILER REPORT OF INSPECTION 441 kb 02/13/2015 Y
10923 COURSE COMPLETION CERTIFICATE 80 kb Y
10926 NOTICE OF SUBSEQUENT OFFERING 45 kb Y
11050 RECONCILED PREMIUM TAX STATEMENT 437 kb 08/15/2013 Y
11051 ESTIMATED PREMIUM TAX STATEMENT 277 kb 02/29/2012 Y
12199 NOTICE OF CLAIM 383 kb 08/08/2011 Y
16259 BUILDING APPLICATION 826 kb 02/12/2014 Y
16824 ANNUAL STATE. FOR INSURANCE PREM. FINANCE COMPANY 107 kb Y
16825 PREMIUM FINANCE APPLICATION 296 kb Y
16836 PREMIUM FINANCE COMPANY BALANCE SHEET 270 kb Y
17017 APP.-PETROLEUM TANK RELEASE COMP. FUND 413 kb 11/18/2011 Y
17118 MEDICAL MALPRACTICE CLAIM REPORT 145 kb Y
17132 PETROLEUM TANK REGISTRATION 515 kb 09/26/2014 Y
17331 EXCAVATION EXPENSES WORKSHEET 457 kb 04/23/2012 Y
17419 SURPLUS LINES ANNUAL TAX STATEMENT 403 kb 12/08/2015 Y
17912 AGENT OF PROCESS-ATTACHMENT A 42 kb Y
17913 SEGREGATED ACCOUNT/CONTENTS OF CONTRACT-ATTACHMENT B 28 kb Y
17914 APPL FOR CERTIFICATE OF EXEMPTION TO ISSUE GIFT ANNUITIES 55 kb Y
18332 UTILIZATION REVIEW FILING REPORT 273 kb 08/12/2008 Y
18378 UTILILIZATION REVIEW AGENT CERTIFICATION 364 kb 02/06/2013 Y
18556 APPLICATION FOR INDIVIDUAL REINSURANCE INTERMEDIARY LICENSE 134 kb Y
18731 ENVIRONMENTAL CONSULTANT EXPENSE WORKSHEET 410 kb 09/09/2010 Y
18739 APP FOR REINSURANCE INTERMEDIARY LICENSE-CORP OR PARTNERSHIP 128 kb N
18956 COMPLAINT QUESTIONNAIRE 231 kb Y
19050 COMPLAINT QUESTIONNAIRE AGENT 194 kb Y
19312 SURETY BOND FOR SELF-INSURERS 317 kb 09/26/2012 Y
50072 CHANGE OF ADDRESS AND/OR NAME 456 kb 07/30/2015 Y
50291 APPOINTMENT/TERMINATION 635 kb 09/13/2016 Y
50502 LIFE SETTLEMENT PROVIDER INDIVIDUAL STATEMENT 752 kb 03/15/2010 Y
50884 SALE OR DISPOSAL OF PETROLEUM STORAGE TANKS 382 kb 09/26/2014 Y
51663 DECLARATION OF COMPLIANCE WITH THE AUTO ACCIDENT REPARATIONS 174 kb Y
51679 POLICY, FORM, AND RATE FILING TRANSMITTAL FORM 76 kb Y
51680 SERFF RETALIATORY FILING FEE FORM 300 kb 08/12/2011 Y
51681 PROSPECTIVE LOSS COSTS REFERENCE FILING-NDPC300 301 kb N
51682 CROP INSURANCE RATE FILING 350 kb Y
51682 CROP INSURANCE FILING - NDPC200 (PRINTABLE) 80 kb N
51683 CONSENT TO RATE APPLICATION 78 kb Y
52090 LIFE ACCIDENT & HEALTH CHECKLIST 1577 kb 11/01/2016 Y
52091 PROPERTY AND CASUALTY INSURERS CHECKLIST 1451 kb 11/01/2016 Y
52092 TITLE COMPANIES CHECKLIST 988 kb 11/01/2016 Y
52094 HEALTH CHECKLIST 1252 kb 11/01/2016 Y
52095 FRATERNAL SOCIETIES CHECKLIST 1457 kb 11/01/2016 Y
52150 APP FOR EXEMPTION BY AUTO RENTAL CO FOR COUNTER SALES PERSON 250 kb 11/28/2007 Y
52579 PAYMENT VOUCHER/AUTHORIZATION 439 kb 10/23/2015 Y
52655 COMMERCIAL ROOF QUESTIONNAIRE 525 kb 11/07/2013 Y
52764 FIRE DISTRICT REPORT 4684 kb 12/29/2016 Y
52864 PTRCF ADVISORY BOARD TRAVEL EXPENSE VOUCHER 549 kb 11/21/2016 Y
53137 COUNTY MUTUAL COMPANIES CHECKLIST 449 kb 11/01/2016 Y
53166 LOSS PREVENTION QUESTIONNAIRE 533 kb 01/13/2012 Y
53881 VOLUNTARY CANCELLATION REQUEST OR REMOVAL OF LINES OF AUTHOR 351 kb 07/28/2015 Y
53913 CERTIFICATE OF ASSUMING INSURER (AR-1) 182 kb Y
53914 APPLICATION FOR REGISTRATION AS A PURCHASING GROUP 310 kb 08/21/2007 Y
53915 APP FOR REGISTRATION AS A RISK RETENTION GROUP (FOREIGN) 405 kb 11/06/2007 Y
53916 REGISTRATION OF APPOINTMENT OF AGENT FOR SERVICE OF PROCESS 188 kb Y
54042 LIFE SETTLEMENT BROKER BUSINESS ENTITY STMT 461 kb 03/15/2010 Y
54043 LIFE SETTLEMENT PROVIDER STATEMENT 699 kb 04/11/2011 Y
54180 LARGE GROUP HEALTH INSURANCE DATA REPORT 85 kb Y
54181 SMALL GROUP HEALTH INSURANCE DATA REPORT 77 kb Y
54182 INDIVIDUAL HEALTH INSURANCE DATA REPORT 100 kb Y
54357 CERTIFICATION AS AN INSURER OF AUTOMOBILE WARRANTY CONTRACTS 360 kb 07/25/2013 Y
54369 APPLICATION FOR COVERAGE 498 kb 10/07/2015 Y
58333 UNIFORM SUSPECTED INSURANCE FRAUD REPORTING 1422 kb 02/21/2008 Y
58370 PRESCRIPTION CONNECTION INTAKE APPLICATION 696 kb 06/14/2012 Y
58427 JOINT UNDERWRITER APPLICATION 168 kb Y
58566 COMMERCIAL BLANKET BOND APP FOR COUNTY GAME & FISH VENDORS 444 kb 03/21/2016 Y
58600 ISSUER CERTIFICATION-LTC PARTNERSHIP PROGRAM 696 kb 10/04/2007 Y
58686 VIATICAL SETTLEMENT PROVIDER INDIVIDUAL STATEMENT 688 kb 10/22/2007 Y
58784 APPLICATION FOR HOBBY BOILER LICENSE 386 kb 02/13/2015 Y
58785 APPLICATION FOR HOBBY BOILER LICENSE EXAMINATION 383 kb 02/13/2015 Y
58786 HOBBY BOILER LICENSE AFFIDVIT AND APPLICATION 422 kb 02/13/2015 Y
58799 CERTIFICATION OF ADVERTISING COMPLIANCE 274 kb 01/27/2011 Y
59018 INFORMATION REQUIRED TO INSURE RADIO TOWERS AND EQUIPMENT 203 kb 01/30/2012 Y
59127 REQUEST FOR LINE OF DUTY DEATH BENEFIT 413 kb 09/21/2011 Y
59438 NOTIFICATION BY LIFE INS PRODUCER OF LIFE SETTLEMENT BROKER 311 kb 04/19/2012 Y
59530 BOILER OR WATER HEATER INSTALLATION REPORT 664 kb 02/13/2015 Y
59883 SURPLUS LINES REPORT OF PLACEMENT 816 kb 06/23/2015 Y
60444 RENEWAL OF A HOBBY BOILER LICENSE 382 kb 02/13/2015 Y
60515 OUTDOOR PROPERTY APPLICATION 278 kb 07/16/2015 Y
60801 REQUEST TO CHANGE THE DESIGNATED RESPONSIBLE LIC PRODUCER 363 kb 08/05/2015 Y
60808 REQUEST FOR LETTER OF CLEARANCE 404 kb 05/23/2016 Y
60894 PORTABLE ELECTRONICS VENDOR ACKNOWLEDGEMENT 363 kb 08/12/2015 Y
60995 CERTIFICATE OF CERTIFIED REINSURER (CR-1) 623 kb 01/05/2016 Y