NAIC FORMS |
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Form |
Description |
Location |
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ACORD Forms |
Free online forms |
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Amendment Form, aka UCAA Corporate Amendment Application |
Uniform Certificate of Authority (UCAA) Filing Form |
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| Annual Antifraud Statistical Report Form | To aid in the uniform collection of antifraud data from insurance companies | http://www.naic.org/store_home.htm | |
Annual Statement Forms - Including exhibits, schedules & supplements |
Required for Annual Statement Filings |
The forms are available from the NAIC Insurance Products and Services Division, http://www.naic.org/store_home.htm |
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| Application Checklist | Uniform Certificate of Authority (UCAA) Filing Form | http://www.naic.org/industry_ucaa_primary.htm#ApplicationChecklist | |
Application for listing in NAIC Directory of Resources to Assist Regulators of Troubled or Insolvent Insurance Companies |
Directory provides a listing of resource consultants for state insurance regulators and others |
Contact the Insolvency Attorney in the NAIC Legal Department |
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Application Form for listing on Bank List |
Securities Valuation Office (SVO) Form |
isis.naic.org/help/html/isis_help_atf_bank_letter_of_credit.htm |
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Application Form - Lloyd's syndicate |
International Insurers Department (IID) Form |
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AR-1 Form: Certificate of Assuming Insurer |
Form regarding Conflict of Interest required by some states |
NAIC Model Credit for Reinsurance Model Regulation and Section 6 Appendixes and Exhibits, Exhibit B, Example Form AR-1 Certificate of Assuming Insurer, Financial Condition Examiners Handbook. Both are available from the NAIC Insurance Products and Services Division, http://www.naic.org/store_home.htm |
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Asset-Backed & Residential Mortgage Backed Securities, aka Structured Security Questionnaire |
Securities Valuation Office (SVO) Form |
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ATF Bank Letter of Credit - See Letter of Credit, aka Approval or Confirmation Letter |
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isis.naic.org/help/html/isis_help_atf_bank_letter_of_credit.htm |
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Authorization for Disclosure of Financial Records |
Uniform Certificate of Authority (UCAA) Filing Form |
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Automated Valuation Service (AVS) Subscription Form |
Full access customers can update their AVS contact and year-end information |
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Biographical Affidavit |
Uniform Certificate of Authority (UCAA) Filing Form, aka Form 11. Includes Disclosure and Authorization Concerning Background Reports |
http://www.naic.org/industry_ucaa.htm and |
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Blanks Agenda Item Submission Form |
To be submitted to the NAIC Blanks (E) Working Group | http://www.naic.org/documents/committees_e_app_blanks_blanksagenda_formdoc.doc |
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Bond Lease Based CTL Application |
Securities Valuation Office (SVO) Form. |
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Business Plan Form |
International Insurers Department (IID) Form |
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Ceded Reinsurance Contract Review |
Reinsurance regulation |
Section 6 Appendixes and Exhibits, Exhibit D General Reinsurance |
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Certificate of Assuming Insurer, aka Form AR-1 |
Reinsurance regulation |
NAIC Model 786, Credit for Reinsurance Model Regulation and Exhibit B, Part 4, Reinsurance: Financial Examiners Handbook Both are available from the NAIC Insurance Products and Services Division http://www.naic.org/store_home.htm |
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Certificate of Compliance Form |
Uniform Certificate of Authority (UCAA) Filing Form |
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Certificate of Deposit Form |
Uniform Certificate of Authority (UCAA) Filing Form |
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Certification of Loss Reserves, aka Loss Reserve Certification Form |
International Insurers Department (IID) Form |
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Change of Address/Contact Notification Form |
Uniform Certificate of Authority (UCAA) Filing Form |
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| Change in control, application | Corporate Amendments: Uniform Certificate of Authority (UCAA) Form | http://www.naic.org/industry_ucaa.htm See 8C, Questionnaire (Corporate Amendments) |
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Collateral Loan Form |
Securities Valuation Office (SVO) Form |
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Commission Agreement for Brokers & Agents |
Uniform Application for Individual Non-Residential License Form and Uniform Application for Business Entity Non-Resident License Form. Includes a section for background information |
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Company Code Application Form |
Application for NAIC Company Code |
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| Complaint Code Form | NAIC Standard Complaint Data Form. Includes codes | http://www.naic.org/documents/committees_d_complaints_cds_form_a.pdf | |
Complaint Record Format |
Complaint Records |
NAIC Model 884, Model Regulation for Complaint Records to be Maintained Pursuant to the NAIC Unfair Trade Practices Act. The model is available from the NAIC Insurance Products and Services Division, http://www.naic.org/store_home.htm |
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| Contact Notification Form, aka Change of Address Form | Uniform Certificate of Authority (UCAA) Filing Form | http://www.naic.org/industry_ucaa.htm | |
Corporate Amendment Application |
Uniform Certificate of Authority (UCAA) Filing Form |
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Corporate Amendments Checklist |
Uniform Certificate of Authority (UCAA) Filing Form |
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Counter party Rating Report aka Form CRR-1 |
Securities Valuation Office (SVO) Form |
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Credit Lease Based CTL Application |
Securities Valuation Office (SVO) Form |
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Credit Tenant Loan Evaluation Form for Bond Lease Based CTL |
Securities Valuation Office SVO Form |
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Credit Tenant Loan Evaluation Form for Credit Lease Based CTL |
Securities Valuation Office SVO Form |
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Custodial Affidavits or |
Form A: For use by a custodian bank where securities entrusted to its care have not been redeposited elsewhere. |
NAIC Model 298, Model Regulation on the Use of Clearing Corporations and Federal Reserve Book-Entry System by Insurance Companies. The model is available from the NAIC Insurance Products and Services Division, http://www.naic.org/store_home.htm |
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Discount Factor Form |
Securities Valuation Office (SVO). Not a form per se |
Filer submits discount information to the SVO on company letterhead |
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Emerging Accounting Issues Working Group Agenda Submission Form B |
Form used by insurer to clarify an accounting issue by the Emerging Accounting Issues Working Group (Emerging) |
http://www.naic.org/documents/committees_e_app_eaiwg_EAIWGAgendaProcess_a.doc |
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Expansion Application |
Uniform Certificate of Authority (UCAA) Filing Form |
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Expansion Checklist |
Uniform Certificate of Authority (UCAA) Filing Form |
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Expedited Filing Transmittal Document for Terrorism Risk Insurance Forms and Pricing |
NAIC form to assist insurers in complying with the Terrorism Risk Insurance Act of 2002. Part of Model Bulletin |
http://www.naic.org/documents/topics_TRIA_Extension_Model_Bulletin.pdf
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Filing Instructions |
International Insurers Department (IID) Form |
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Financial Database Participation Packet |
Instructions and materials for Annual Statement electronic filings |
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Financial Filing Format aka IID Financial Filing Format |
International Insurers Department (IID) Form |
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Form A State Role Request Form |
Oracle User Administration. Request for IDs or Roles from the Form A Database |
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Form A Filing aka Statement Concerning the Acquisition of Control or or Merger with a Domestic Insurer |
Statement Concerning the Acquisition of Control or Merger with a Domestic Insurer |
Form A is part of NAIC Model 450: Insurance Holding Company System Model Regulation with Reporting Forms and Instructions. The forms are intended to be used as guides only. To obtain a copy of blank forms, contact state insurance departments. The Model is available from the NAIC Insurance Products and Services Division, www.naic.org/store_home.htm. |
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Form M-1 for Annual Report for Multiple Employer Welfare Arrangements (MEWAs) |
MEWA" M-1 Form"—This is not an NAIC form. It is available from the Department of Labor. |
Department of Labor: http://www.dol.gov/ebsa/pdf/2002M1Form.pdf |
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Fraud Reporting Form and instructions |
aka Uniform Suspected Insurance Fraud Reporting Form |
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General Reinsurance Checklist |
Reinsurance regulation |
Section 6 Appendixes and Exhibits, Exhibit C, General Reinsurance Checklist, Financial Condition Examiners Handbook. Available from the NAIC Insurance Products and Services Division, http://www.naic.org/store_home.htm |
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Holding Company Reporting Forms Section 4 of NAIC Model 450: Insurance Company System Model Regulation with Reporting Forms and Instructions states: "Forms A, B, C, D, & E are intended to be guides in the presentation of the statements required by Sections 3,3.1, 4 & 5 of the Act. They are not intended to be blank forms which are to be filled in." |
Form A: "Statement Regarding the Acquisition of Control of or Merger with a Domestic Insurer". |
NAIC Model 450: Insurance Holding Company System Model Regulation with Reporng Forms and Instructions. .Note: .The forms are intended to be guides only. To obtain a copy of blank forms, contact state insurance departments. The model is available from the NAIC Insurance Products and Services Division, http://www.naic.org/store_home.htm |
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IID Interrogatories for Lloyd's Syndicates |
International Insurers Department (IID) Form |
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Information Systems Controls Questionnaire aka ISQ |
Used by Financial Examiners |
Financial Condition Examiners Handbook, Part 1 (General) Exhibit C. This publication is available from from the NAIC Insurance Products and Services Division, http://www.naic.org/store_home.htm |
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Insurance Holding Company System Annual Registration Statement |
Form B: "Insurance Holding Company System Model Regulation with Reporting Forms and Instructions" |
NAIC Model 450: Insurance Holding Company System Model Regulation with Reporting Forms and Instructions. The model is available from the NAIC Insurance Products and Services Division, http://www.naic.org/store_home.htm |
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Insurehub website |
Free online forms by name, by number & by state. Also Acord & Countrywide Forms |
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| Interactive Life, Accident & Health Annuity, Credit Transmittal Document | Transmittal Documents | http://www.naic.org/documents/industry_rates_LHtransDoc_interactive.pdf http://www.naic.org/documents/industry_rates_lh_trans.doc http://www.naic.org/documents/industry_rates_lh_trans_instructions.pdf |
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| Interactive Property & Casualty Transmittal Document and instructions | Transmittal Documents | http://www.naic.org/documents/industry_rates_PCtransDoc_intelligent.pdf http://www.naic.org/documents/industry_rates_pc_trans.%20doc.doc http://www.naic.org/documents/industry_rates_pc_trans_instructions.pdf |
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ISO Policywriting Support Forms |
Insurance Services Office |
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Jurat - Standard IID Financial ReportingForm |
International Insurers Department (IID) Form |
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Letter of Credit |
Directions for an
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isis.naic.org/help/html/isis_help_atf_bank_letter_of_credit.htm |
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Uniform Letter of Credit Form |
NAIC Model 795: Reinsurance: A Model Act for the Regulation of Reserves Ceded to Nonadmitted Reinsurers. Appendix. The model is available from the NAIC Insurance Products and Services Division, http://www.naic.org/store_home.htm |
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Letter of Credit Definition |
NAIC Model 280: Investments of Insurers Model Act, p 280-10. The model is available from the NAIC Insurance Products and Services Division |
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Letter of Credit Form |
Reinsurance regulation |
Section 6 Appendixes and Exhibits, Exhibit A Example Let5ter of Credit Form, Financial Condition Examiners Handbook. Available from the NAIC Insurance Products and Services Division, http://www.naic.org/store_home.htm |
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| Life, Accident & Health Annuity Credit Additional Rate Attachment | Transmittal Document | http://www.naic.org/documents/industry_rates_lh_rate.pdf http://www.naic.org/documents/industry_rates_lh_rate.doc |
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| Life, Accident & Health , Annuity, Credit Form Filing Attachment | Transmittal Document | http://www.naic.org/documents/industry_rates_lh_form.pdf http://www.naic.org/documents/industry_rates_lh_form.doc |
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Life Insurance & Annuities Replacement Forms |
Appendix A, B, & C Life Insurance and Annuities Replacement Model Regulation |
NAIC Model 613: Life Insurance and Annuities Replacement Model Regulation. The model is available from the NAIC Insurance Products and Services Division, http://www.naic.org/store_home.htm |
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Lines of Insurance |
Uniform Certificate of Authority (UCAA) Filing Form |
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Long Term Care Insurance Forms: Rescission Reporting Form, Personal Worksheet ,Things You Should Know, Suitability Letter, Claims Denial Form & Replacement/ Lapse Reporting Form |
Appendix A-G: Long Term Care Insurance Model Regulation |
NAIC Model 641:Long Term Care Insurance Model Regulation is available from the NAIC Insurance Products and Services Division, http://www.naic.org/store_home.htm |
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Long Term Care Insurance Report Form |
For departmental use |
NAIC Model 645: Proposed Circular Letter and Report Form for Gathering Information on LTC Policies /Long Term Care Insurance Report Form is available from the NAIC Insurance Products and Services Division, http://www.naic.org/store_home.htm |
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Loss Cost Filing Form Formerly Reference Filing Adoption Form |
For departmental use (other than Workers comp) |
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Loss Reserve Certification Form aka Certification of Loss Reserves |
International Insurers Department (IID) Form. |
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Market Conduct Database |
Forms to complete for Market Conduct Annual Statement |
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Matrix of State Requirements |
Non-resident licensing requirements/Uniform Application for Individual Non-Resident License |
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Medical Malpractice Claim Report Form, aka NAIC Medical Professional Liability Insurance Uniform Claims Report |
For departmental use |
Page 6, NAIC Malpractice Claims, Final Compilation, 1975-1978. This publication is available from the NAIC Insurance Products and Services Division, http://www.naic.org/store_home.htm |
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Medicare Supplement Form for Reporting Medicare Supplement Policies |
Appendix B: Medicare Supplement Insurance Regulation |
NAIC Model 651: Medicare Supplement Insurance Regulation is available from the NAIC Insurance Products and Services Division http://www.naic.org/store_home.htm |
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Medicare Supplement Refund Calculations Form |
Appendix A: Medicare Supplement Insurance Regulation |
NAIC Model 651: Medicare Supplement Insurance Regulation is available from the NAIC Insurance Products and Services Division, http://www.naic.org/store_home.htm |
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Medicare Supplement Reporting Form for the Calculation of Benchmark Ratio Since Inception for Individual Policies |
Appendix A: Medicare Supplement Insurance Regulation |
NAIC Model 651: Medicare Supplement Insurance Regulation is available from the NAIC Insurance Products and Services Division, http://www.naic.org/store_home.htm |
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| MEWA – Annual report for Multiple Employer Welfare Arrangements – Form M1 | MEWA M1-Form is not an NAIC form. It is available from the Dept of Labor | Department of Labor: http://www.dol.gov/ebsa/pdf/2002M1Form.pdf |
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Mutual Fund Filing |
Securities Valuation Office (SVO) Form |
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NAIC Medical Professional Liability Insurance Uniform Claims Report |
For departmental use |
Page 6, NAIC Malpractice Claims, Final Compilation, 1975-1978. This publication is available from the NAIC Insurance Products and Services Division, http://www.naic.org/store_home.htm |
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| NAIC Standard Complaint Form | For departmental use |
Appendix A (A-18) Market Conduct Examiners Handbook. This publication is available from the NAIC Insurance Products and Services Division, http://www.naic.org/store_home.htm |
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NAIC Uniform Continuing Education Reciprocity Project, aka NAIC CE Reciprocity (CER) Process |
Part of Midwest Zone Continuing Education Reciprocity Plan. Part of Uniform Regulation thru Technology (URTT) Program |
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NAIC Uniform Review Standards Checklist |
SERFF (System for Electronic Rate and Form Filing) Form |
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Notice of Regulatory Activity (RIRS Form) |
For submission of regulatory actions reported to the NAIC. Includes NAIC RIRS codes. |
I-SITE (rirsform_2) (Regulators only) |
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Notice of Transfer and Response Card |
Appendix A of Assumption Reinsurance Model Act re Transfer Policy |
NAIC Model 803, Assumption Reinsurance Model Act, is available from the NAIC Insurance Products and Services Division, http://www.naic.org/store_home.htm |
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Office & Directors Form |
Instructions for completing in Annual Supplement section of Annual Statement Instructions |
The blanks do not contain an example. The form is usually available in company's vendor software. The form is available from the NAIC Insurance Products and Services Division, http://www.naic.org/store_home.htm |
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P & I Multiple Issues |
Securities Valuation Office (SVO). New versions accommodating amendment to the 5* 6* Rules. |
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P & I Procedures |
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P & I Single Issue |
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Paper Based Filings - State Form |
SERIFF Instructions for industry or state to create a paper transmittal form |
http://www.naic.org/documents/industry_rates_pc_trans_instructions.pdf Effective January 1, 2003, These 3 pages are informational only and do not need to be submitted with filings. |
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Plan of Operation for listing of alien non-admitted insurers aka IID Plan of Operation |
International Insurers Department (IID) Form |
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Policyholder Disclosure Notice of Terrorism Insurance Coverage |
NAIC form to assist insurers in complying with the Terrorism Insurance Act of 2002 |
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Power and Pipe Line Annual Review Summary |
Securities Valuation Office (SVO) Form. |
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Power of Attorney to Appoint/Certify Agents |
Uniform Certificate of Authority (UCAA) Filing Form |
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Pre-Acquisition Notification Form |
Form E: "Insurance Holding Company System Model Regulation with Reporting Forms and Instructions". |
NAIC Model 450, Insurance Holding Company System Model Regulation with Reporting Forms and Instructions. The model is available from the NAIC Insurance Products and Services Division, http://www.naic.org/store_home.htm |
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Primary Application Form |
Uniform Certificate of Authority (UCAA) Filing Form |
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Primary Checklist |
Uniform Certificate of Authority (UCAA) Filing Form |
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Principal and Interest Certification Forms, |
SVO. New versions to accommodate amendment to the 5* 6* Rules. |
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Prior Notice of a Transaction |
Form D: "Insurance Holding Company System Model Regulation with Reporting Forms and Instructions". |
NAIC Model 450 Insurance Holding Company System Model Regulation with Reporting Forms and Instructions. The model is available from the NAIC Insurance Products and Services Division, http://www.naic.org/store_home.htm |
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Private Placement Memorandum, aka Guide 6 Form. See Valuation Information Memorandum (VIM) |
Securities Valuation Office (SVO) Form |
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Pro Forma Financial Statements:
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Uniform Certificate of Authority (UCAA) Filing Form |
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Project Information Memorandum |
Securities Valuation Office (SVO) Form |
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| Property & Casualty Additional Form Attachment | Transmittal Documents | http://www.naic.org/documents/industry_rates_pc_form.pdf http://www.naic.org/documents/industry_rates_pc_form.doc |
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| Property & Casualty Additional Rate Attachment | Transmittal Documents | http://www.naic.org/documents/industry_rates_pc_rate.pdf http://www.naic.org/documents/industry_rates_pc_rate.doc |
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Purchasing Group Form-Notice & Registration Form, Part A, aka Uniform Application for Purchasing Group Form |
Uniform Registration Form for Securities Acquisition Report (SAR) |
Appendix E, Risk Retention & Purchasing Group Handbook, Handbook. The handbook is available from the NAIC Insurance Products and Services Division, http://www.naic.org/store_home.htm |
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Purchasing Group Form-Appointment of Attorney to Accept Service & Designation, Part B |
Uniform Registration Form for Securities Acquisition Report (SAR) |
Appendix E, Risk Retention & Purchasing Group Handbook, The handbook is available from the NAIC Insurance Products and Services Division, http://www.naic.org/store_home.htm |
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Quarterly Listing Application Form |
International Insurers Department (IID) Form |
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Questionnaire (Primary & Expansion) |
Uniform Certificate of Authority (UCAA) Filing Form |
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Questionnaire (Corporate Amendments) |
Uniform Certificate of Authority (UCAA) Filing Form |
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RTAS Application |
To facilitate use of the Regulatory Treatment Analysis service |
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Regulatory Treatment Analysis Service Application (RTAS) |
To facilitate use of the Regulatory Treatment Analysis service |
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Replacement of Life Insurance or Annuities Form, aka Life Insurance or Annuities Replacement |
Appendix A, B, & C Life Insurance and Annuities Replacement Model Regulation |
NAIC Model 613: Life Insurance and Annuities Replacement Model Regulation. The model is available from the NAIC Insurance Products and Services Division, http://www.naic.org/store_home.htm |
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Replication (Synthetic Asset) Transactions Forms |
Securities Valuation Office (SVO) Forms |
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Residential Mortgage Quality Matrix Model |
Designed to provide filers with a tool for calculating residential mortgage pool quality scores pursuant to filing an application to the SVO |
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| RIRS FORM - Notice of Regulatory Activity | For submission of regulatory actions reported to the NAIC. Includes NAIC RIRS codes | I-SITE (rirsform_2) (Regulators only) | |
Risk Retention Reporting Form |
Uniform Registration Form for Securities Acquisition Report (SAR) |
Appendix C, Risk Retention & Purchasing Group Handbook. The handbook is available from the NAIC Insurance Products and Services Division, http://www.naic.org/store_home.htm |
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Risk Retention Group - Notice and Registration Form, Part A |
Uniform Registration Form for Securities Acquisition Report (SAR) |
Appendix D, Risk Retention & Purchasing Group Handbook. The handbook is available from the NAIC Insurance Products and Services Division, http://www.naic.org/store_home.htm |
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Risk Retention Group Form - Appointment of Attorney to Accept Service & Designation, Part B |
Uniform Registration Form for Securities Acquisition Report (SAR). |
Appendix D, Risk Retention & Purchasing Group Handbook. The handbook is available from the NAIC Insurance Products and Services Division, http://www.naic.org/store_home.htm |
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Risk Retention Purchasing Group - Notice and Registration Form. See Purchasing Group - Notice and Registration Forms |
Uniform Registration Form for Securities Acquisition Report (SAR). |
Appendix E,Risk Retention & Purchasing Group Handbook. The handbook is available from the NAIC Insurance Products and Services Division, http://www.naic.org/store_home.htm |
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Self Certification Form |
SERFF (System for Electronic Rate and Form Filing) Form |
http://www.naic.org/documents/industry_rates_self_cert_pilot.pdf |
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Security Acquisition Report (SAR) |
Securities Valuation Office (SVO) Filing |
A type of filing created on ISIS. An ATF (Authorization To File ) is created and submitted to the NAIC within 120 days of an insurance company’s acquisition of a security. The process for generating an SAR can be found under internet filings on www.naic.org/. You must have a login and password to create an ATF |
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Short Form Application For Written Consent to Engage in the Business of Insurance under the Provisions of the Violent Crime Control & Law Enforcement Act of 1984 |
Short form (.pdf) |
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Standard Certification Form |
Used to verify the status of an agent who is seeking a non-resident licenser |
NAIC Model 212: Standard Certification Form. The model is available from the NAIC Insurance Products and Services Division, http://www.naic.org/store_home.htm |
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Standard Financial Filing Format, Jurat |
International Insurers Department (IID) |
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Standard Form Trust Agreement for Alien Excess or Surplus Lines Insurers |
International Insurers Department (IID) |
http://www.naic.org/IID_docs/trust.doc | |
Standard Letter of Clearance |
Used to verify the status of an agent's license in his/her state of domicile when the agent is seeking to be licensed as a registered agent in another state |
NAIC Model 213: Standard Letter of Clearance. The model is available from the NAIC Insurance Products and Services Division, http://www.naic.org/store_home.htm |
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Statement Regarding the Acquisition of Control of or Merger with a Domestic Insurer |
Database allowing on-line entry of data from the Statement Concerning the Acquisition of Control or Merger with a Domestic Insurer.Also: Form A in Model 450: Insurance holding Company System Model Regulation with Reporting Forms & Instructions |
To access Form A Role Request Form: http://www.naic.org/members_tech_ua_formastrrform.htm Also in NAIC Model 450: Insurance Holding Company Model Regulation with Reporting Forms & Instructions. The model is available from the NAIC Insurance Products and Services Division, http://www.naic.org/store_home.htm |
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Statutory Accounting Principles Working Group Maintenance Agenda Submission Form A |
Used by insurer to request clarification on an accounting issue by the Statutory Accounting Principles Working Group (SAPWG) |
http://www.naic.org/documents/committees_e_app_eaiwg_EAIWGAgendaProcess_a.doc |
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Structured Security Questionnaire (Asset-Backed & Residential Mortgage Backed Securities) |
Securities Valuation Office (SVO) Form |
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Summary of Registration Statement |
Form C: Model 450, Insurance Holding Company System Model Regulation with Reporting Forms & Instructions |
NAIC Model 450: Insurance Holding Company System Model Regulation with Reporting Forms & Instructions. The model is available from the NAIC Insurance Products and Services Division, http://www.naic.org/store_home.htm |
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Surplus Line Premium Tax Allocation Schedule – Criteria for Tax Allocation of Multi-State Risks |
Appendix A: Model 872 |
NAIC Model 872: Allocation of Surplus Lines & Independently Procured Insurance Premium Tax on Multi-state Risk Model Regulation, http://www.naic.org/store_home.htm |
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SVO Compliance Certification |
Securities Valuation Office (SVO) Form |
Annual Statement General Instructions section |
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Tax Allocation Report |
Appendix B: Model 872 |
NAIC Model 872: Allocation of Surplus Lines & Independently Procured Insurance Premium Tax on Multi-state Risk Model Regulation, http://www.naic.org/store_home.htm |
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Transmittal Documents |
SERIFF Instructions for industry or state to create a paper transmittal form |
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Treasury Stock Form aka Treasury Stock and Reciprocal Ownership Elimination Worksheet |
Securities Valuation Office (SVO) Form |
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TRIA Schedule |
Lloyd’s Syndicate Annual Filing |
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UCAA Proposal Form |
To accompany proposals to modify UCAA documents |
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UCAA State Role Request Form |
Oracle User Administration. UCAA Form |
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UCAA State Specific Information |
Additional authorizations other than Certificate of Authority |
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Uniform Application for Individual and Business Entity License/Registration Form |
Uniform Application adopted by the Producer Licensing Working Group |
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Uniform Application for Business Entity License (a uniform non-resident application form) |
Uniform Non-Resident Applications |
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Uniform Application for Individual License (a non-resident application form) |
Uniform Non-Resident Applications |
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Uniform Appointment/Termination Form and Procedures |
Uniform Application adopted by the Producer Licensing Working Group |
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Uniform Certificate of Authority (USCC) Application, Checklist & Forms |
Uniform Certificate of Authority (UCAA) Filing Form |
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Uniform Claim Forms - Health |
Descriptions & requirements. |
NAIC Model 30, Standardized Health Claim Form Model Regulation. The model is available from the NAIC Insurance Products and Services Division, http://www.naic.org/store_home.htm |
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Uniform Consent to Service of Process (Expansion & Corporate Amendments only) |
Uniform Certificate of Authority (UCAA) Filing Form |
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Uniform Producer and Business Entity Renewal/Continuation Application, aka Uniform Insurance License Renewal/Continuation Form |
Uniform Application form adopted by the Producer Licensing Working Group |
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Uniform Producer and Business Entity Reinstatement Application |
Uniform Application form adopted by the Producer Licensing Working Group |
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Uniform Producer Application for Individual Resident/Nonresident License |
NIPR Uniform Resident Licensing and Licensing Reciprocity Form |
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Uniform Product Coding Matrix |
SERFF Instructions for industry or state to create a paper transmittal form |
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Uniform Registration Form |
see Risk Retention Group Form & Purchasing Group Form. |
Risk Retention & Purchasing Group Handbook. The handbook is available from the NAIC Insurance Products and Services Division, http://www.naic.org/store_home.htm |
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Uniform Request for Company Appointment/Cancellation Form |
Not an NAIC Form |
Contact State Department of Insurance |
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Uniform TPA Application, aka Application for Third Party Administrator License/Registration |
Uniform Application form adopted by the Producer Licensing Working Group |
http://www.naic.org/committees_d_producer_licensing.htm and NAIC Proceedings, 3rd Quarter. September, 2001, Attachment One-B-1, Market Conduct & Consumer Affairs (D) Committee, p 196 |
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Valuation Information Memorandum (VIM) For Securities not Rated by an SVO Recognized Rating Agency |
Securities Valuation Office (SVO) Form. |
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Verification of Coverage for Life Insurance Policies aka VOC form |
To be completed by Viatical Settlement Provider or Broker |
NAIC Model 698: Viatical Settlement Model Regulation, Appendix B. The model is available from the NAIC Insurance Products and Services Division, http://www.naic.org/store_home.htm |
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Viatical Settlement Provider/Broker Report. Includes Individual Mortality Report & Viatical Settlement Provider/Broker Certification Form |
To be completed by Viatical Settlement Provider or Broker |
NAIC Model 698: Viatical Settlement Model Regulation, Appendix C. The model is available from the NAIC Insurance Products and Services Division, http://www.naic.org/store_home.htm |
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