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 Health Insuring Corporation Forms

 
Form NumberForm Title
INS0505Provider Complaint Form
INS5036Standardized Credentialing Form Part B
INS7062Internet & Diskette Submissions of A/S to NAIC
INS7140Exhibit A Tax Credit - All Foreign & Domestic Insurers
INS7141Domestic Health Insuring Corporation Franchise Tax Form
INS7145Foreign Health Insuring Corporation Premium Tax Form
INS7160Filing of Audited Financial Statements
INS7166Audited Financial Statement Exemption Affidavit
INS7168Financial Disclosure Form - HIC's
INS7213Bar Coding Instructions
INS7215Foreign & Alien Insurance Tax Summary
INS7221Review of Application for Approval of Acquisition of Domestic Insurer (Form A)
INS7226Exhibit of Premiums Enrollment and Utilization - HMO
INS7239Dividend/Distribution Notification Filing ORC 3901.33; 3901.34⌐; 3901.37(B)
INS7240Electronic Filing Authenticity Affidavit
INS7257Disclosure And Authorization Concerning Background Reports - Mergers and Acquisitions
INS9008Requirements for HIC Major Modification
INS9011Filing Requirements for COA or Service Area Expansion Request
INS9012Flesch Reading Ease Test
INS9014HIC Deposit & Filing Fee Schedule
INS9016HIC Provider / HCF Contract Certification Form
INS9022HIC Solicitation Review Guidelines & Checklist
INS9025Quality Assurance Programs Certification of Compliance
INS9026Utilization Review Programs Certification of Compliance
INS9027External Independent Review Process Certification of Compliance
INS9032Instructions for Application for a Health Insuring Corporation Certificate of Authority
INS9036Rate Filing Guidelines
INS9060Form of Required $250000.00 Deposit
INS9071Guaranty
INS9073Application for a Health Insuring Corporation Certificate of Authority
INS9074Filing Requirements For Service Area Expansion Request
Performance Bond Form for Medicaid HICs
 

 Life and Health Company Forms

 
Form NumberForm Title
INS0100Fraud Complaint Form (Company)
INS0510Insurers Issuing Life Insurance Policies Certification of Compliance Appendix A
INS5001Life Insurance Company Certification of Filing Compliance with ORC 3916.05(B) and OAC Rule 3901-9-04
INS5002Life Insurer Application Form STOLI Question Review Guidelines
INS5033Certification of External Review Procedures
INS5036Standardized Credentialing Form Part B
INS6012Enforcement Complaint Form
INS6013Agent Termination For Cause Form
INS7001Insurance Regulatory Information System
INS7004Application for Certificate of Authority - Fraternal Benefit Societies Mutual Protective Associations and Title Companies
INS7006Application For Certificate of Authority - Life
INS7008Statement of Actuarial Opinion Exemption Affidavit for Insurance Companies*
INS7062Internet & Diskette Submissions of A/S to NAIC
INS7140Exhibit A Tax Credit - All Foreign & Domestic Insurers
INS7142Domestic Life Insurance Company Franchise Tax Form
INS7146Foreign Life Insurance Company Premium Tax Form
INS7160Filing of Audited Financial Statements
INS7166Audited Financial Statement Exemption Affidavit
INS7213Bar Coding Instructions
INS7215Foreign & Alien Insurance Tax Summary
INS7221Review of Application for Approval of Acquisition of Domestic Insurer (Form A)
INS7226Exhibit of Premiums Enrollment and Utilization - HMO
INS7239Dividend/Distribution Notification Filing ORC 3901.33; 3901.34⌐; 3901.37(B)
INS7240Electronic Filing Authenticity Affidavit
INS7257Disclosure And Authorization Concerning Background Reports - Mergers and Acquisitions
NAIC Application For Written Consent To Engage In The Business Of Insurance (1033)
 

 Property & Casualty and Title Company Forms

 
Form NumberForm Title
INS0100Fraud Complaint Form (Company)
INS4012Property and Casualty Profit & Loss Statement
INS4023Statement of Premium Taxes for Unauthorized Insurers
INS6012Enforcement Complaint Form
INS6013Agent Termination For Cause Form
INS7001Insurance Regulatory Information System
INS7004Application for Certificate of Authority - Fraternal Benefit Societies Mutual Protective Associations and Title Companies
INS7005Application For Certificate of Authority - P&C
INS7008Statement of Actuarial Opinion Exemption Affidavit for Insurance Companies*
INS7014Ohio Automobile Insurance Plan (Auto Ins.)
INS7015Ohio Fair Plan Underwriting Association (Homeowners/property)
INS7016Ohio Fire Marshal Tax Return
INS7062Internet & Diskette Submissions of A/S to NAIC
INS7140Exhibit A Tax Credit - All Foreign & Domestic Insurers
INS7143Domestic Property & Casualty Franchise Tax Form
INS7144Domestic Fire Assessment Association Franchise Tax Form
INS7147Foreign Property & Casualty Premium Tax Form
INS7148Dividend Deductions For Premium Taxes - Foreign P&C Insurers
INS7150Computation of Deposits - Domestic Title Co's
INS7151Computation of Deposits - Domestic Title & Trust Co's
INS7152Computation of Deposits - Foreign Title Co's
INS7160Filing of Audited Financial Statements
INS7166Audited Financial Statement Exemption Affidavit
INS7186Exemption Affidavit For Actuarial Opinion - Ohio Titles
INS7213Bar Coding Instructions
INS7214Domestic Insurance Tax Summary
INS7215Foreign & Alien Insurance Tax Summary
INS7219Cost Sharing Agreement Review (Form D)
INS7221Review of Application for Approval of Acquisition of Domestic Insurer (Form A)
INS7239Dividend/Distribution Notification Filing ORC 3901.33; 3901.34⌐; 3901.37(B)
INS7240Electronic Filing Authenticity Affidavit
INS7257Disclosure 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

 


 

The State of Ohio is an Equal Opportunity Employer

Ohio Department of Insurance
50 W. Town Street, Third Floor - Suite 300
Columbus, Ohio  43215
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John Kasich, Governor | Mary Taylor, Lt. Governor / Director
General Info: 614-644-2658 | Consumer Hotline: 800-686-1526
Fraud Hotline: 800-686-1527 | OSHIIP Hotline: 800-686-1578