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Insurer Forms

Captive Insurance

 
 
 

Health Insuring Corporation Forms

 
Form Number Form Title
INS0505 Provider Complaint Form
INS5036 Standardized Credentialing Form Part B
INS7062 Internet & Diskette Submissions of A/S to NAIC
INS7140 Exhibit A Tax Credit - All Foreign & Domestic Insurers
INS7141 Domestic Health Insuring Corporation Franchise Tax Form
INS7145 Foreign Health Insuring Corporation Premium Tax Form
INS7160 Filing of Audited Financial Statements
INS7166 Audited Financial Statement Exemption Affidavit
INS7168 Financial Disclosure Form - HIC's
INS7214 Domestic Insurance Tax Summary
INS7215 Foreign & Alien Insurance Tax Summary
INS7221 Review of Application for Approval of Acquisition of Domestic Insurer (Form A)
INS7226 Exhibit of Premiums Enrollment and Utilization - HMO
INS7239 Dividend/Distribution Notification Filing ORC 3901.33, 3901.34(C), 3901.37(B), 3964.06
INS7240 Electronic Filing Authenticity Affidavit
INS7257 Disclosure And Authorization Concerning Background Reports - Mergers and Acquisitions
INS9008 Requirements for HIC Major Modification
INS9011 Filing Requirements for COA or Service Area Expansion Request
INS9012 Flesch Reading Ease Test
INS9014 HIC Deposit & Filing Fee Schedule
INS9016 HIC Provider / HCF Contract Certification Form
INS9022 HIC Solicitation Review Guidelines & Checklist
INS9025 Quality Assurance Programs Certification of Compliance
INS9026 Utilization Review Programs Certification of Compliance
INS9027 External Independent Review Process Certification of Compliance
INS9032 Instructions for Application for a Health Insuring Corporation Certificate of Authority
INS9036 Rate Filing Guidelines
INS9060 Form of Required $250000.00 Deposit
INS9071 Guaranty
INS9073 Application for a Health Insuring Corporation Certificate of Authority
INS9074 Filing Requirements For Service Area Expansion Request
Performance Bond Form for Medicaid HICs
 
 

Life and Health Company Forms

 
Form Number Form Title
INS0100 Fraud Complaint Form (Company)
INS0510 Insurers Issuing Life Insurance Policies Certification of STOLI Prevention Procedures
INS5001 Life Insurance Company Certification of Filing Compliance with ORC 3916.05(B) and OAC Rule 3901-9-04
INS5002 Life Insurer Application Form STOLI Question Review Guidelines
INS5033 Certification of External Review Procedures
INS5036 Standardized Credentialing Form Part B
INS6012 Enforcement Complaint Form
INS6013 Agent Termination For Cause Form
INS7001 Insurance Regulatory Information System
INS7004 Application for Certificate of Authority - Fraternal Benefit Societies Mutual Protective Associations and Title Companies
INS7006 Application For Certificate of Authority - Life
INS7008 Statement of Actuarial Opinion Exemption Affidavit for Insurance Companies*
INS7062 Internet & Diskette Submissions of A/S to NAIC
INS7140 Exhibit A Tax Credit - All Foreign & Domestic Insurers
INS7142 Domestic Life Insurance Company Franchise Tax Form
INS7146 Foreign Life Insurance Company Premium Tax Form
INS7160 Filing of Audited Financial Statements
INS7166 Audited Financial Statement Exemption Affidavit
INS7214 Domestic Insurance Tax Summary
INS7215 Foreign & Alien Insurance Tax Summary
INS7221 Review of Application for Approval of Acquisition of Domestic Insurer (Form A)
INS7226 Exhibit of Premiums Enrollment and Utilization - HMO
INS7239 Dividend/Distribution Notification Filing ORC 3901.33, 3901.34(C), 3901.37(B), 3964.06
INS7240 Electronic Filing Authenticity Affidavit
INS7257 Disclosure And Authorization Concerning Background Reports - Mergers and Acquisitions
NAIC Application For Written Consent To Engage In The Business Of Insurance (1033)
 
 

MEWA

 
 
 

Property & Casualty and Title Company Forms

 
Form Number Form Title
INS0100 Fraud Complaint Form (Company)
INS4012 Property and Casualty Profit & Loss Statement
INS4023 Direct Procurement Statement
INS6012 Enforcement Complaint Form
INS6013 Agent Termination For Cause Form
INS7001 Insurance Regulatory Information System
INS7004 Application for Certificate of Authority - Fraternal Benefit Societies Mutual Protective Associations and Title Companies
INS7005 Application For Certificate of Authority - P&C
INS7008 Statement of Actuarial Opinion Exemption Affidavit for Insurance Companies*
INS7014 Ohio Automobile Insurance Plan (Auto Ins.)
INS7015 Ohio Fair Plan Underwriting Association (Homeowners/property)
INS7016 Ohio Fire Marshal Tax Return
INS7062 Internet & Diskette Submissions of A/S to NAIC
INS7140 Exhibit A Tax Credit - All Foreign & Domestic Insurers
INS7143 Domestic Property & Casualty Franchise Tax Form
INS7144 Domestic Fire Assessment Association Franchise Tax Form
INS7147 Foreign Property & Casualty Premium Tax Form
INS7148 Dividend Deductions For Premium Taxes - Foreign P&C Insurers
INS7150 Computation of Deposits - Domestic Title Co's
INS7151 Computation of Deposits - Domestic Title & Trust Co's
INS7152 Computation of Deposits - Foreign Title Co's
INS7160 Filing of Audited Financial Statements
INS7166 Audited Financial Statement Exemption Affidavit
INS7186 Exemption Affidavit For Actuarial Opinion - Ohio Titles
INS7214 Domestic Insurance Tax Summary
INS7215 Foreign & Alien Insurance Tax Summary
INS7219 Cost Sharing Agreement Review (Form D)
INS7221 Review of Application for Approval of Acquisition of Domestic Insurer (Form A)
INS7239 Dividend/Distribution Notification Filing ORC 3901.33, 3901.34(C), 3901.37(B), 3964.06
INS7240 Electronic Filing Authenticity Affidavit
INS7257 Disclosure And Authorization Concerning Background Reports - Mergers and Acquisitions
Adoption of Rating Bureau Prospective Loss Cost
Calculation of Company Loss Cost Multiplier
NAIC Application For Written Consent To Engage In The Business Of Insurance (1033)
Ohio Title Agent Surety Bond
 
 

Statutory Company Deposit Forms

 
 
 

Surplus Lines, Risk Retention Groups, Risk Purchasing Groups

 

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Ohio Department of Insurance
50 W. Town Street, Third Floor - Suite 300
Columbus, Ohio  43215
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Mike DeWine, Governor | Jillian Froment, Director
General Info: 614-644-2658 | Consumer Hotline: 800-686-1526
Fraud Hotline: 800-686-1527 | Medicare Hotline: 800-686-1578