Forms

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Check our filings section for instructions on how to make new forms filings.

Admissions Forms (FAQs)

Advertising Compliance Form

Application for Approval to write Excess & Surplus Lines Ins (MO 375-0474)

Application for Registration as a Purchasing Group (MO 375-0030)

Application for Registration as a Risk Retention Group (MO 375-0029)

Uniform Certificate of Authority Application (from the NAIC)

Application for Certificate of Authority (MO 375-0558) (24 Kb)

Appointment of Director to Receive Service of Process (MO 375-0462) (58 Kb)

Authorized Reinsurer Application and Information (MO 375-1793) (221 Kb)

Discount Medical Plan Organization Registration Form (Form DM-1) (141  KB)
Managing General Agent Contract (MO 375-0038) (56 Kb)

Annual Filings

Notification of Insurer/Trust Agreement(MO 375-1684)

Application to Renew Certificate of Authority (MO 375-0079) (24Kb)

Certificate of Valuation (MO 375-0420) (44 Kb)

Market Value of Securities Request (MO 375-0421)(40 Kb)

Affidavit: Certificate of Compliance with Advertising Rules (PDF, 14 KB)

General Instructions (PDF, 42 KB)

Assessment Companies Checklist (PDF, 29 KB)

Fair Plan Checklist(PDF, 28 KB)

Fraternal Societies (PDF, 102 KB)

Health Entities Checklist (PDF, 97 KB)

Life, Accident and Health Insurers Checklist (PDF, 113 KB)

Prepaid Dental Checklist (PDF, 85 KB)

Property & Casualty Insurers Checklist (PDF, 104 KB)

Authorized Reinsurers Checklist (PDF, 28 KB)

Title Companies Checklist (PDF, 82 KB)

Title Premium Reserve (MO 375-0418) (PDF, 259 KB)

Third-Party Administrator Affidavit (PDF, 39Kb)

Statement of Basket Clause Investments (PDF, 41Kb)

Statement of Basket Clause for P&C (MO 375-0097) (PDF, 42Kb)

Supplement to Annual Statement - Fees Between Insurers and Affiliates (PDF, 111 KB)

          Missouri Mutual Annual Statement Instructions (PDF, 161Kb)

Bail Bond and Surety Recovery Agents

Frequently Asked Questions

Missouri Uniform Application for Bail Bond or Surety Recovery License (Form B1)(MO 375-0112) (245 Kb)

Missouri Uniform Renewal Application for Bail Bond or Surety Recovery License (Form BR)(MO 375-0113) (175 Kb)

Bail Bond Agent, General Bail Bond Agent, and Surety Recovery Agent Continuing Education Certification Summary (MO 375-0107) (42 Kb)
General Bail Bond Agent Assignment (MO 375-0525) (27 Kb)

Acknowledgement of Assignment (MO 375-0527) (27 Kb)

Change of Bail Bond Status (MO 375-0031) (27 Kb)

Change of General Bail Bond Status (MO 375-0032) (26 Kb)

Change of Surety Recovery Status (MO 375-0103) (26 Kb)

General Bail Bond Affidavit (MO 375-0034) (27 Kb)

Approved Initial Basic Training Providers

Initial Basic Training Application (102 Kb)

Captive Insurance Forms

Irrevocable Letter of Credit (MO 375-0591) (41.2 Kb)
Actuary application (375-0598) (43 Kb)
Independent CPA application (375-0596) (43.1 Kb)
Captive application for admission (375-0597) (53.1 Kb)

          Captive Premium Tax Return (375-0599) (98 Kb)

Continuing Education

• Providers

Note: Producers should use the forms in the Producers list to report continuing education courses taken.

Continuing Education Provider Application for Course Approval (MO 375-1575) (84 Kb)

NAIC Uniform Continuing Education Reciprocity Course Filing Form

NAIC Uniform Continuing Education Reciprocity Course Filing Form State Matrix

Continuing Education Certificate of Course Completion (MO 375-0092) (48 Kb) (Form to be completed by course provider only)

CE Providers - Agent/Producer

Affidavit of Exam Proctor (MO 375-0102)(48 Kb)

• Bail Bond

Bail Bond Agent, General Bail Bond Agent, and Surety Recovery Agent Continuing Education Provider Application for Course Approval (MO 375-0109) (98 Kb)

Bail Bond Agent, General Bail Bond Agent, and Surety Recovery Agent Continuing Education Certificate of Course Completion (MO 375-0106) (42 Kb)

Bail Bond Agent, General Bail Bond Agent, and Surety Recovery Agent Affidavit of Exam Proctor (MO 375-0108) (39 Kb)

Consumer Fraud

Fraud Investigation Report for Insurers (MO 375-1785) (161 Kb)

On-line Fraud Investigation Report for Insurers

Missouri Fraud Reporting Requirements For Insurers

HMO/Managed Care

Checklists

Compliance Certificate for Health Care Provider Contracts (74 Kb)

Certificate of Registration Application for Utilization Review Agents (MO 375-0049) (89 Kb)

HMO Access Plan Instructions

HMO Credentialing

Life and Health Forms

Checklists

Transmittal Document (TD-1) (9 Kb)

Medicare Supplement Rate Filing Document (MO 375-0065) (12 Kb) | Excel 97

Actuarial Certification--Small Employers Health Insurance Availability Act (42 Kb)

Affidavit for Health Benefit Plans issued to Association with Small and Large Employers (20 CSR 400 - 2.135) (42 Kb)

Long-Term Care Partnership Forms

LTC-1 Notice to Applicant Regarding Replacement Form (PDF, 15.5 KB)

LTC-2 Notice to Applicant Regarding Replacement for DR Form (PDF, 14.4 KB)

LTC-3 Outline of Coverage Form (PDF, 24.4 KB)

LTC-4 Long Term Care Partnership Exchange Notification Form (PDF, 17.7 KB)

LTC-5 Long Term Care Partnership Program Policy Certification Form (PDF, 25.2 KB)

LTC-6 Long Term Care Insurance Partnership Disclosure Notice (PDF, 19 KB)

LTC-7 Long Term Care Insurance Partnership Delivery Notice (PDF, 19.3 KB)

LTC-A Rescission Reporting Form (PDF, 12.7 KB)

LTC-B Personal Worksheet Form (PDF, 17.3 KB)

LTC-C Things You Should Know Before You Buy Form (PDF, 21.3 KB)

LTC-D Suitability Letter Form (PDF, 11.9 KB)

LTC-E Claims Denial Reporting Form (PDF, 28.6 KB)

LTC-F Potential Rate Increase Form (PDF, 40.2 KB)

LTC-G Replacement and Lapse Report Form (PDF, 14.9 KB)

Property and Casualty Forms

Transmittal Document (TD-2) (12 Kb)

P&C Rate Filings

Rate Filing Form (Exhibit A) (64 Kb)

Calculation of Loss Cost Multiplier (Exhibit B) (58 Kb)

Expense Constant Supplement (Exhibit C) (43 Kb)

Producer Forms

Notice: As of January 1, 2003, all producer application fees increased to $100. See bulletin 02-04 for details.

Frequently Asked Questions

Electronic Resident/Non-Resident Licensing and Renewal

Electronic Address Change

Uniform Application for Resident Individual Insurance Producer License

Uniform Application for Non-Resident Individual Producer License

Uniform Application for Resident Business Entity License/Registration

Uniform Application for Non-Resident Business Entity License/Registration

Organizational Credit Business Entity Application (MO 375-0096) (240 Kb)

Continuing Education Certification Summary (MO 375-0091) (57 Kb)

Change of Producer Status (MO 375-0085) (60 Kb)

Change of Business Entity Producer Status (MO 375-0087) (76 Kb)

Change of Organizational Credit Business Entity Status(MO 375-0099) (1.02 MB)

Public Adjuster Bond (MO 375-0033) (594 Kb)
Change of Public Adjuster Status (MO 375-0067) (110 Kb)
Change of Public Adjuster Solictor Status (375-0070) (76 Kb)

Self-Procured Insurance Tax Report--Appendix 4 (MO 375-0498) (117 Kb)

Missouri Uniform Application for Public Adjuster, Public Adjuster Soliciter, or Surplus Lines (MO 375-0111) (238 Kb)

1033 Waiver Application Form (105 kb)

Reinsurance Intermediary Forms

Reinsurance Intermediary Application (57 Kb)

Regulation 20 CSR 700-7.100

Statute 375.1110 to 1140

Service Contract Forms

Instructions for Motor Vehicle Extended Service Contract Provider Initial Registration (MO 375-0585) (118 KB)
Instructions for Service Contract Provider Initial Registration (MO 375-0586) (120 KB)
Instructions for Motor Vehicle Extended Service Contract Provider Renewal (MO 375-0676) (121 KB)
Instructions for Service Contract Provider Renewal (MO 375-0675) (122 KB)

Statistics

Dram Shop Liability Insurance Premium and Loss Report (MO 375-0100) (PDF, 38 Kb) Instructions for reporting Dram Shop Liability (6 Kb)

Legal Malpractice Claim Report (MO 375-1662) (45 Kb)

Medical Professional Liability Insurance Claim Report (MO 375-0304) (45 Kb)

Medicare Supplement Insurance Experience Report (MO 375-0307) (44 Kb)

Missouri Commercial Liability Profitability Report (MO 375-0359) (108 Kb) and

Commercial Liability Closed and Outstanding Claim Form

Instructions for Completing MO 375-0359

Products Liability Closed Claim Report (MO 375-1663) (49 Kb)

Real Estate Malpractice Claim Report (MO 375-1661) (45 Kb)

Annual Statement Supplement (MO 375-1802) (79 Kb)

Instructions for MO 375-1802

Page 19 Supplement to Annual Statement (MO 375-0381) (84 Kb)

Instructions for MO 375-0381

Tax Forms (FAQs)

Casualty Insurance Companies ( MO 375-0409) (124 Kb)

Life Insurance Companies ( MO 375-0411) (105 Kb)

Chapter 380 Missouri Mutual Companies ( MO 375-0429) (73 Kb)

2008 Insurance Producers Report (62 Kb)

2009 Quarterly Administrative Surcharge Report Form (68 Kb)

Prior Year Tax Information

Third-Party Administrators

Administrator Application (MO 375-1685) (26 Kb)

Biographical Affidavit (MO 375-0536) (34 Kb)

Bond of Third Party Administrator (MO 375-1811) (5 Kb)

TPA Questionnaire (MO 375-0083) (53 Kb)

Title

T-1 Title Insurance Premium and Title Service Charge Disclosure Statement   (14 Kb)
T-2 Notice of Availability of Owner's Title Insurance   (15 KB)
T-3 Notice of Closing or Settlement Risk   (13 KB)
T-4 Affiliated Business Disclosure  (10 KB)
T-5A Agency Financial Interest Report (13 KB)
T-5B Affiliated Business Arrangement Report (11 KB)
T-6A Missouri Title Insurer's Statutory Onsite Review Report (892 KB)
T-6B Missouri Title Insurer's Onsite Review Sampling Methods (750 KB)
T-7 Uniform Premium (Risk Rate) Report (31 KB)
T-8 Seller's Closing Protection Letter  (16KB)
T-8 Seller's Closing Protection Letter (16 KB)
T-9 Lender's Closing Protection Letter (18 KB)
T-9 Lender's Closing Protection Letter (18 KB)
T-12 Annual Title Plant Registration (15 KB)
Individual Application (UA-IP)
Business Entity Application (UA-BEP)

Vehicle Protection Product Forms

Instructions for Missouri Vehicle Protection Product Registration (375-0686) 9-08 (120 Kb)

Workers Compensation

Diskette Form (5 Kb) (Instructions)

Independent Rate Filing Form (Exhibit A) (19 Kb)

Rate Development Summary Form (Exhibit B) (33 Kb)

Second Injury Fund Surcharge Forms (link to the Department of Labor Division of Workers Comp)

Limited Liability Company Exclusion Endorsements (15 Kb)

Self-Insured Tax Return (Table 1) (322 Kb)