NAIC FORMS
For part of models and publications, contact the library at reslib@naic.org.

Form

 Description

Location

ACORD Forms

 

Free online forms

 

www.insureHub.com

 

Amendment Form, aka UCAA Corporate Amendment Application

 

Uniform Certificate of Authority (UCAA) Filing Form

 

http://www.naic.org/industry_ucaa_corp_amend.htm

 

 

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

 

 

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

 

Application Form for listing on Bank List

 

Securities Valuation Office (SVO) Form

 

Contact Corporate Securities Group of the SVO

 

Application Form - Lloyd's syndicate

 

International Insurers Department (IID) Form

 

http://www.naic.org/committees_c_surplus_lines_iid_plan.htm

 

 

AR-1 Form: Certificate of Assuming Insurer

 

Form re Conflict of Interest required by some states

NAIC Model 786: Credit for Reinsurance Model Regulation and Section 6, Exhibit B. Example Form AR-1 in Financial Condition Examiners Handbook. Both are available from the NAIC Insurance Products and Services Division, http://www.naic.org/store_home.htm

 

 

Asset-Backed & Residential Mortgage Backed Securities, aka Structured Security Questionnaire

 

Securities Valuation Office (SVO) Form

 

http://www.naic.org/svo.htm

 

See Filing Applications and Forms

 

ATF Bank Letter of Credit - See Letter of Credit, aka Approval or Confirmation Letter

 

ISIS filing of Bank List

 

isis.naic.org/help/html/isis_help_atf_bank_letter_of_credit.htm

Authorization for Disclosure of Financial Records

 

Uniform Certificate of Authority (UCAA) Filing Form

 

http://www.naic.org/industry_ucaa.htm

 

 

Authorization to File System (ATF)

SVO Filings

https://isis.naic.org/help/html/isis_help_atf.htm

(See Help Index )

 

Automated Valuation Service (AVS) Subscription Form

 

Full access customers can update their AVS contact and year-end information

 

isis.naic.org/help/html/isis_help_avs_yearend_contact.htm

 

 

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

 

http://www.naic.org/committees_c_surplus_lines_iid_plan.htm

 

 

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

 

 

Bond Lease Based CTL Application

 

Securities Valuation Office (SVO) Form

http://www.naic.org/documents/svo_bondctl.doc

Business Plan Form

 

International Insurers Department (IID) Form

 

http://www.naic.org/committees_c_surplus_lines_iid_plan.htm

 

Ceded Reinsurance Contract Review

 

Reinsurance regulation

 

Section 6, Exhibit D Ceded Reinsurance Contract Review, Financial Condition Examiners Handbook. Available from the NAIC Insurance Products and Services Division, http://www.naic.org/store_home.htm

 

 

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

 

 

Certificate of Compliance Form

 

Uniform Certificate of Authority (UCAA) Filing Form

 

http://www.naic.org/industry_ucaa.htm

 

 

Certificate of Deposit Form

 

Uniform Certificate of Authority (UCAA) Filing Form

 

http://www.naic.org/industry_ucaa.htm

 

 

Certification of Loss Reserves, aka Loss Reserve Certification Form

 

International Insurers Department (IID) Form

 

http://www.naic.org/committees_c_surplus_lines_iid_plan.htm

 

 

Change of Address/Contact Notification Form

 

Uniform Certificate of Authority (UCAA) Filing Form

 

http://www.naic.org/industry_ucaa.htm

 

 

Change in control, application

Corporate Amendments: Uniform Certificate of Authority (UCAA) Form

http://www.naic.org/industry_ucaa.htm

See 8C, Questionnaire (Corporate Amendments)

 

Collateral Loan Form

 

Securities Valuation Office (SVO) Form

 

http://www.naic.org/svo.htm

 

See Filing Applications and Forms

 

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

 

http://www.nipr.com/non_resident_paper_licensing.htm

 

 

Company Code Application Form

 

Application for NAIC Company Code Number

 

http://www.naic.org/documents/industry_company_code_app.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

 

 

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

 

http://www.naic.org/industry_ucaa_corp_amend.htm

 

 

Corporate Amendments Checklist

 

Uniform Certificate of Authority (UCAA) Filing Form

 

http://www.naic.org/industry_ucaa.htm

 

 

Counter party Rating Report aka Form CRR-

Securities Valuation Office (SVO) Form

http://www.naic.org/svo.htm

See Filing Applications and Forms

Credit Lease Based CTL Application

 

Securities Valuation Office (SVO) Form

 

http://www.naic.org/svo.htm

See Filing Applications and Forms

 

Credit Tenant Loan Evaluation Form for Bond Lease Based CTL

 

Securities Valuation Office SVO Form

 

http://www.naic.org/svo.htm

See Filing Applications and Forms

Credit Tenant Loan Evaluation Form for Credit Lease Based CTL

 

Securities Valuation Office SVO Form

 

http://www.naic.org/svo.htm

See Filing Applications and Forms

 

Custodial Affidavits or

Custodian Agreements

 

Form A: For use by a custodian bank where securities entrusted to its care have not been redeposited elsewhere.

Form B: For use where a custodian bank maintains securities on deposit with The Depository Trust Company or like entity.

Form C: For use where ownership is evidenced by book entry at a Federal Reserve Bank.

 

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

 

 

Discount Factor Form

 

Securities Valuation Office (SVO).

Not a form per se: Filer submits discount information to the SVO on company letterhead

 

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/committees_e_app_eaiwg.htm

 

 

Expansion Application

 

Uniform Certificate of Authority (UCAA) Filing Form

 

http://www.naic.org/industry_ucaa_expansion.htm

 

 

Expansion Checklist

 

Uniform Certificate of Authority (UCAA) Filing Form

 

http://www.naic.org/industry_ucaa.htm

 

 

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

 

 

Filing Instructions

 

International Insurers Department (IID) Form

 

http://www.naic.org/committees_c_surplus_lines_iid_plan.htm

 

Financial Database Participation Packet

 

Instructions and materials for Annual Statement electronic filings

 

http://www.naic.org/industry_financial_filing.htm

 

 

Financial Filing Format aka IID Financial Filing Format

 

International Insurers Department (IID) Form

 

http://www.naic.org/committees_c_surplus_lines_iid_plan.htm

 

 

Form A State Role Request Form

 

Oracle User Administration. Request for IDs or Roles from the Form A Database

 

http://www.naic.org/members_tech_ua_formastrrform.htm

 

 

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

 

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

 

 

Fraud Reporting Form and instructions

 

aka Uniform Suspected Insurance Fraud Reporting Form

 

http://www.naic.org/committees_d_antifraud.htm

 

 

General Reinsurance Checklist

 

Reinsurance regulation

 

Section 6, 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

 

 

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".

Form B: "Insurance Holding Company System Annual Registration Statement".

Form C: "Summary of Registration Statement".

Form D: "Prior Notice of a Transaction".

Form E: "Pre-Acquisition Notification Form".

 

NAIC Model 450: Insurance Holding Company System Model Regulation with Reporting 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

 

 

IID filing pack IID Filing Instructions for Lloyd's Syndicates http://www.naic.org/IID_docs/Lloyds_Filing_Instructions.doc

IID Interrogatories for Lloyd's Syndicates

 

International Insurers Department (IID) Form

 

http://www.naic.org/committees_c_surplus_lines_iid_plan.htm

 

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

 

 

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

 

 

Insurehub website

 

Free online forms by name, by number & by state.

 

www.InsureHub.com

 

 

Interactive Life, Accident & Health Annuity, Credit Transmittal Document

Transmittal Documents

http://www.naic.org/industry_rates_forms_trans_docs.htm

 

 

Interactive Property & Casualty Transmittal Document and instructions

Transmittal Documents

http://www.naic.org/industry_rates_forms_trans_docs.htm

ISO Policy writing Support Forms

Insurance Services Office

http://www.iso.com

 

 

Jurat - Standard IID Financial Reporting Form

 

International Insurers Department (IID) Form

 

http://www.naic.org/committees_c_surplus_lines_iid_plan.htm

 

 

Letter of Credit

 

Directions for an ISIS filing for the Bank List (banks which meet the credit standards of the SVO)

 

isis.naic.org/help/html/isis_help_atf_bank_letter_of_credit.htm

 

 

Letter of Credit Definition

 

Definition/Investments

NAIC Model 280: Investments of Insurers Model Act (Defined Limits Version) Article I, Section 1 XX. The model is available from the NAIC Insurance Products and Services Division. http://www.naic.org/store_home.htm

Letter of Credit Form

Reinsurance regulation

Section 6, Exhibit A Example Letter of Credit Form, Financial Condition Examiners Handbook. Available from the NAIC Insurance Products and Services Division, http://www.naic.org/store_home.htm

 

 

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

 

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

 

Life Insurance & Annuities Replacement Forms

Aka:NAIC Notice of Replacement Letter

 

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

 

 

Lines of Insurance

 

Uniform Certificate of Authority (UCAA) Filing Form

 

http://www.naic.org/industry_ucaa.htm

 

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

 

 

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

 

Loss Cost Forms

 

Information about operating in a loss cost system

 

http://www.naic.org/industry_rates_forms_loss_cost.htm

 

Loss Reserve Certification Form aka Certification of Loss Reserves

 

International Insurers Department (IID) Form.

http://www.naic.org/committees_c_surplus_lines_iid_plan.htm

 

 

Market Conduct Database

 

Forms to complete for Market Conduct Annual Statement

 

http://www.naic.org/industry_market_conduct_statement.htm

 

 

Matrix of State Requirements

 

Non-resident licensing requirements/Uniform Application for Individual Non-Resident License

 

http://www.nipr.com/non_resident_paper_licensing.htm

 

 

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

 

 

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

 

 

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

 

 

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

 

 

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

 

 

Mutual Fund Filing aka ATF Mutual Fund

 

SVO Form

 

https://isis.naic.org/help/html/isis_help_atf_mutual_fund.htm

 

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

 

 

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

 

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

 

http://www.naic.org/urtt_cer.htm

 

 

NAIC Uniform Review Standards Checklist

 

SERFF (System for Electronic Rate and Form Filing) Form

 

http://www.naic.org/industry_rates_forms_ursc.htm

 

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)

 

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

 

 

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

 

 

P & I Multiple Issues

 

P & I Procedures

 

P & I Single Issue

 

 

 

 

Securities Valuation Office (SVO). New versions accommodating amendment to the 5* 6* Rules.

 

http://www.naic.org/svo.htm

 

See Filing Applications and Forms

 

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.

 

 

 

Plan of Operation for listing of alien non-admitted insurers aka IID Plan of Operation

 

International Insurers Department (IID) Form

 

http://www.naic.org/committees_c_surplus_lines_iid_plan.htm

 

 

Policyholder Disclosure Notice of Terrorism Insurance Coverage

 

NAIC form to assist insurers in complying with the Terrorism Insurance Act of 2002

 

http://www.naic.org/documents/topics_tria_disclose1.pdf

 

Power and Pipe Line Annual Review Summary

 

Securities Valuation Office (SVO) Form.

 

http://www.naic.org/svo.htm

See Filing Applications and Forms

 

Power of Attorney to Appoint/Certify Agents

 

Uniform Certificate of Authority (UCAA) Filing Form

 

http://www.naic.org/industry_ucaa.htm

 

 

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

 

 

Primary Application Form

 

Uniform Certificate of Authority (UCAA) Filing Form

 

http://www.naic.org/industry_ucaa.htm

 

 

Primary Checklist

 

Uniform Certificate of Authority (UCAA) Filing Form

 

http://www.naic.org/industry_ucaa.htm

 

 

Principal and Interest Certification Forms,

aka P&I Single and Multiple Issues.

 

SVO. New versions to accommodate amendment to the 5* 6* Rules.

 

http://www.naic.org/svo.htm

 

See Filing Applications and Forms

 

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

 

 

Private Placement Memorandum, aka Guide 6 Form. See Valuation Information Memorandum (VIM)

 

Securities Valuation Office (SVO) Form

 

http://www.naic.org/svo.htm

 

See Filing Applications and Forms

 

Pro Forma Financial Statements:

Property/Casualty Companies

 

 

Life/Health Companies

 

 

Title Companies

 

Uniform Certificate of Authority (UCAA) Filing Form

 

http://www.naic.org/industry_ucaa.htm

 

 

Project Information Memorandum

 

Securities Valuation Office (SVO) Form

 

http://www.naic.org/svo.htm

 

See Filing Applications and Forms

 

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

 

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

 

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

 

 

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

 

 

Questionnaire (Primary & Expansion)

 

Uniform Certificate of Authority (UCAA) Filing Form

 

http://www.naic.org/industry_ucaa.htm

 

 

Questionnaire (Corporate Amendments)

 

Uniform Certificate of Authority (UCAA) Filing Form

 

http://www.naic.org/industry_ucaa.htm

 

 

RTAS Application

 

Regulatory Treatment Analysis Service

To facilitate use of the Regulatory Treatment Analysis service

 

 

http://www.naic.org/documents/svo_rtas_app.pdf

 

 

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

 

 

Replication (Synthetic Asset) Transactions Forms

 

Securities Valuation Office (SVO) Forms

 

http://www.naic.org/svo.htm

 

See Filing Applications and Forms

 

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

 

http://www.naic.org/svo.htm

 

See Filing Applications and Forms

 

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

 

 

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

 

 

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

 

 

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

 

 

Self Certification Form

 

SERFF (System for Electronic Rate and Form Filing) Form

 

http://www.naic.org/documents/industry_rates_self_cert_pilot.pdf

 

 

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

 

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)

 

http://www.naic.org/documents/library_forms_1033shor.pdf

 

 

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

 

 

Standard Financial Filing Format, Jurat

 

International Insurers Department (IID)

 

http://www.naic.org/IID_docs/jurat.doc

 

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

 

 

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

 

 

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

 

Structured Security Questionnaire (Asset-Backed & Residential Mortgage Backed Securities)

Securities Valuation Office (SVO) Form

 

http://www.naic.org/documents/svo_Ambsqa8.doc

 

 

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

 

 

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

 

 

SVO Compliance Certification

 

Securities Valuation Office (SVO) Form

 

Annual Statement General Instructions section

 

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

 

Transmittal Documents

 

SERIFF Instructions for industry or state to create a paper transmittal form

http://www.naic.org/industry_rates_forms_trans_docs.htm

 

 

Treasury Stock Form aka Treasury Stock and Reciprocal Ownership Elimination Worksheet

 

Securities Valuation Office (SVO) Form

 

http://www.naic.org/svo.htm

See Filing Applications and Forms

 

TRIA Schedule

 

Lloyd’s Syndicate Annual Filing

 

http://www.naic.org/committees_c_surplus_lines_iid_plan.htm

 

 

UCAA Proposal Form

 

To accompany proposals to modify UCAA documents

 

http://www.naic.org/industry_ucaa.htm

 

 

UCAA State Role Request Form

 

Oracle User Administration. UCAA Form

 

http://www.naic.org/members_tech_ua_ucaarrform.htm

 

 

UCAA State Specific Information

 

Additional authorizations other than Certificate of Authority

 

http://www.naic.org/industry_ucaa.htm

 

 

Uniform Application for Individual and Business Entity License/Registration Form

 

Uniform Application adopted by the Producer Licensing Working Group

 

http://www.naic.org/documents/committees_ex_pltf_plwg_0809_indapp_w_revisions.doc

 

 

 

Uniform Application for Business Entity License (a uniform non-resident application form)

Uniform Non-Resident Applications

http://www.naic.org/documents/committees_ex_pltf_plwg_0809_busren_w_revisions.pdf

 

Uniform Application for Individual License (a non-resident application form)

 

Uniform Non-Resident Applications

 

http://www.naic.org/documents/committees_ex_pltf_plwg_0809_indapp_w_revisions.doc

 

Uniform Appointment/Termination Form and Procedures

 

Uniform Application adopted by the Producer Licensing Working Group

 

http://www.naic.org/documents/committees_ex_pltf_plwg_uniform_appt_term.doc

 

 

 

Uniform Certificate of Authority (USCC) Application, Checklist & Forms

 

Uniform Certificate of Authority (UCAA) Filing Form

 

http://www.naic.org/industry_ucaa.htm

 

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

 

 

Uniform Consent to Service of Process (Expansion & Corporate Amendments only)

 

Uniform Certificate of Authority (UCAA) Filing Form

 

http://www.naic.org/industry_ucaa.htm

 

 

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

 

http://www.naic.org/documents/committees_ex_pltf_plwg_0809_busren_w_revisions.pdf

 

Uniform Producer Application for Individual Resident/Nonresident License

 

NIPR Uniform Resident Licensing and Licensing Reciprocity Form

 

http://www.nipr.com/resident_paper_licensing.htm

 

 

Uniform Product Coding Matrix

 

SERFF Instructions for industry or state to create a paper transmittal form

 

http://www.naic.org/documents/industry_rates_pc_matrix.pdf

 

 

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

 

 

Uniform Request for Company Appointment/Cancellation Form

 

Not an NAIC Form

 

Contact State Department of Insurance

 

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_ex_pltf_producer_licensing.htm

or

NAIC Proceedings, 3rd Quarter. September, 2001, Attachment One-B-1, Market Conduct & Consumer Affairs (D) Committee, p 196

 

Valuation Information Memorandum (VIM) For Securities not Rated by an SVO Recognized Rating Agency

 

Securities Valuation Office (SVO) Form

http://www.naic.org/svo.htm See Filing Applications and Forms

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

 

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