Forms

Because of the new Adobe forms technology, it is highly recommended that Internet Explorer 11 or later is used for accessing PDF forms whenever possible. If you must use Chrome or Firefox, please follow the instructions listed below.

Adobe PDF Viewer

PDF forms require an Adobe PDF Viewer browser plug-in. The latest versions of Chrome and Firefox do not support this technology by default. Some additional configurations need to be made to these browsers in order for them to work properly. Depending on your version of Chrome or Firefox, the instructions may vary slightly. When possible, use Internet Explorer 11 or higher. Microsoft Edge is not recommended or supported. In any case, Adobe Reader needs to be installed on your machine. After Adobe Reader is installed, proceed with the instructions below for your specific browser.

Chrome

Replace the Chrome built in PDF viewer so that you can open, view, and save PDF's without issues.

  • Type into the address window of Chrome browser: chrome://settings/content
  • Scroll down and click on PDF documents
  • Slide the slider to the right next to Open PDFs using a different application
  • Click on a form number hyperlink
  • Click on the up arrow on the pdf download box in lower left corner of screen
  • Choose Always open in Adobe Reader
Firefox

Trying to open PDFs in Firefox could result in an error message that states "This PDF document contains forms. The filling of form fields is not supported."

To get the form to open in Adobe, you need to do the following:

  • Open Firefox
  • Click the Tools menu button
  • Click Options and select Applications
  • Find Portable Document Format (PDF) in the Content Type column
  • In the Action column, change it to Use Adobe Acrobat

Insurance Department - Public Form(s)

SFNTitleSizeDateFillable
3380 COVERAGE CHANGES ON CURRENT PROPERTY INS 181 kb 01/13/2012 Y
4792 DATA PROCESSING QUESTIONNAIRE 39 kb Y
4795 AFFIDAVIT 167 kb Y
4805 COUNTY MUTUAL ABSTRACT OF STATEMENT 157 kb 11/26/2012 Y
4818 SURPLUS LINES AFFIDAVIT 328 kb 06/28/2012 Y
4824 SURPLUS LINES ANNUAL PLACEMENT REPORT 677 kb 12/08/2015 Y
7832 FIRE INSURANCE PREMIUMS AND LOSSES 231 kb Y
8330 AGENT FOR SERVICE OF PROCESS 205 kb 01/12/2009 Y
9576 NOTICE OF LOSS 274 kb 01/20/2012 Y
10706 BOILER REPORT OF INSPECTION 441 kb 02/13/2015 Y
10923 COURSE COMPLETION CERTIFICATE 80 kb Y
10926 NOTICE OF SUBSEQUENT OFFERING 45 kb Y
11050 RECONCILED PREMIUM TAX STATEMENT 437 kb 08/15/2013 Y
11051 ESTIMATED PREMIUM TAX STATEMENT 277 kb 02/29/2012 Y
12199 NOTICE OF CLAIM 383 kb 08/08/2011 Y
16259 BUILDING APPLICATION 826 kb 02/12/2014 Y
16824 ANNUAL STATE. FOR INSURANCE PREM. FINANCE COMPANY 107 kb Y
16825 PREMIUM FINANCE APPLICATION 296 kb Y
16836 PREMIUM FINANCE COMPANY BALANCE SHEET 270 kb Y
17017 APP.-PETROLEUM TANK RELEASE COMP. FUND 413 kb 11/18/2011 Y
17118 MEDICAL MALPRACTICE CLAIM REPORT 145 kb Y
17132 PETROLEUM TANK REGISTRATION 515 kb 09/26/2014 Y
17331 EXCAVATION EXPENSES WORKSHEET 457 kb 04/23/2012 Y
17419 SURPLUS LINES ANNUAL TAX STATEMENT 401 kb 11/06/2017 Y
17912 AGENT OF PROCESS-ATTACHMENT A 42 kb Y
17913 SEGREGATED ACCOUNT/CONTENTS OF CONTRACT-ATTACHMENT B 28 kb Y
17914 APPL FOR CERTIFICATE OF EXEMPTION TO ISSUE GIFT ANNUITIES 55 kb Y
18332 UTILIZATION REVIEW FILING REPORT 882 kb 11/01/2017 Y
18378 UTILILIZATION REVIEW AGENT CERTIFICATION 434 kb 07/03/2017 Y
18556 APPLICATION FOR INDIVIDUAL REINSURANCE INTERMEDIARY LICENSE 134 kb Y
18731 ENVIRONMENTAL CONSULTANT EXPENSE WORKSHEET 410 kb 09/09/2010 Y
18739 APP FOR REINSURANCE INTERMEDIARY LICENSE-CORP OR PARTNERSHIP 128 kb N
18956 COMPLAINT QUESTIONNAIRE 231 kb Y
19050 COMPLAINT QUESTIONNAIRE AGENT 194 kb Y
19312 SURETY BOND FOR SELF-INSURERS 317 kb 09/26/2012 Y
50072 CHANGE OF ADDRESS AND/OR NAME 456 kb 07/30/2015 Y
50291 APPOINTMENT/TERMINATION 635 kb 09/13/2016 Y
50502 LIFE SETTLEMENT PROVIDER INDIVIDUAL STATEMENT 752 kb 03/15/2010 Y
50884 SALE OR DISPOSAL OF PETROLEUM STORAGE TANKS 382 kb 09/26/2014 Y
51663 DECLARATION OF COMPLIANCE WITH THE AUTO ACCIDENT REPARATIONS 174 kb Y
51679 POLICY, FORM, AND RATE FILING TRANSMITTAL FORM 76 kb Y
51680 SERFF RETALIATORY FILING FEE FORM 300 kb 08/12/2011 Y
51681 PROSPECTIVE LOSS COSTS REFERENCE FILING-NDPC300 301 kb N
51682 CROP INSURANCE RATE FILING 350 kb Y
51682 CROP INSURANCE FILING - NDPC200 (PRINTABLE) 80 kb N
51683 CONSENT TO RATE APPLICATION 78 kb Y
52090 LIFE ACCIDENT & HEALTH CHECKLIST 1577 kb 11/01/2016 Y
52091 PROPERTY AND CASUALTY INSURERS CHECKLIST 1451 kb 02/08/2017 Y
52092 TITLE COMPANIES CHECKLIST 988 kb 11/01/2016 Y
52094 HEALTH CHECKLIST 1252 kb 11/01/2016 Y
52095 FRATERNAL SOCIETIES CHECKLIST 1457 kb 11/01/2016 Y
52150 APP FOR EXEMPTION BY AUTO RENTAL CO FOR COUNTER SALES PERSON 250 kb 11/28/2007 Y
52579 PAYMENT VOUCHER/AUTHORIZATION 439 kb 10/23/2015 Y
52655 COMMERCIAL ROOF QUESTIONNAIRE 525 kb 11/07/2013 Y
52764 FIRE DISTRICT REPORT 4684 kb 12/29/2016 Y
52864 PTRCF ADVISORY BOARD TRAVEL EXPENSE VOUCHER 549 kb 11/21/2016 Y
53137 COUNTY MUTUAL COMPANIES CHECKLIST 449 kb 11/01/2016 Y
53166 LOSS PREVENTION QUESTIONNAIRE 533 kb 01/13/2012 Y
53881 VOLUNTARY CANCELLATION REQUEST OR REMOVAL OF LINES OF AUTHOR 351 kb 07/28/2015 Y
53913 CERTIFICATE OF ASSUMING INSURER (AR-1) 182 kb Y
53914 APPLICATION FOR REGISTRATION AS A PURCHASING GROUP 310 kb 08/21/2007 Y
53915 APP FOR REGISTRATION AS A RISK RETENTION GROUP (FOREIGN) 405 kb 11/06/2007 Y
53916 REGISTRATION OF APPOINTMENT OF AGENT FOR SERVICE OF PROCESS 188 kb Y
54042 LIFE SETTLEMENT BROKER BUSINESS ENTITY STMT 461 kb 03/15/2010 Y
54043 LIFE SETTLEMENT PROVIDER STATEMENT 699 kb 04/11/2011 Y
54180 LARGE GROUP HEALTH INSURANCE DATA REPORT 85 kb Y
54181 SMALL GROUP HEALTH INSURANCE DATA REPORT 77 kb Y
54182 INDIVIDUAL HEALTH INSURANCE DATA REPORT 100 kb Y
54357 CERTIFICATION AS AN INSURER OF AUTOMOBILE WARRANTY CONTRACTS 360 kb 07/25/2013 Y
54369 APPLICATION FOR COVERAGE 491 kb 09/22/2017 Y
58333 UNIFORM SUSPECTED INSURANCE FRAUD REPORTING 1422 kb 02/21/2008 Y
58370 PRESCRIPTION CONNECTION INTAKE APPLICATION 696 kb 06/14/2012 Y
58427 JOINT UNDERWRITER APPLICATION 168 kb Y
58566 COMMERCIAL BLANKET BOND APP FOR COUNTY GAME & FISH VENDORS 444 kb 03/21/2016 Y
58600 ISSUER CERTIFICATION-LTC PARTNERSHIP PROGRAM 696 kb 10/04/2007 Y
58686 VIATICAL SETTLEMENT PROVIDER INDIVIDUAL STATEMENT 688 kb 10/22/2007 Y
58784 APPLICATION FOR HOBBY BOILER LICENSE 386 kb 02/13/2015 Y
58785 APPLICATION FOR HOBBY BOILER LICENSE EXAMINATION 383 kb 02/13/2015 Y
58786 HOBBY BOILER LICENSE AFFIDVIT AND APPLICATION 422 kb 02/13/2015 Y
58799 CERTIFICATION OF ADVERTISING COMPLIANCE 274 kb 01/27/2011 Y
59127 REQUEST FOR LINE OF DUTY DEATH BENEFIT 413 kb 09/21/2011 Y
59438 NOTIFICATION BY LIFE INS PRODUCER OF LIFE SETTLEMENT BROKER 311 kb 04/19/2012 Y
59530 BOILER OR WATER HEATER INSTALLATION REPORT 664 kb 02/13/2015 Y
59883 SURPLUS LINES REPORT OF PLACEMENT 816 kb 06/23/2015 Y
60444 RENEWAL OF A HOBBY BOILER LICENSE 382 kb 02/13/2015 Y
60515 OUTDOOR PROPERTY APPLICATION 278 kb 07/16/2015 Y
60801 REQUEST TO CHANGE THE DESIGNATED RESPONSIBLE LIC PRODUCER 363 kb 08/05/2015 Y
60808 REQUEST FOR LETTER OF CLEARANCE 404 kb 05/23/2016 Y
60894 PORTABLE ELECTRONICS VENDOR ACKNOWLEDGEMENT 363 kb 08/12/2015 Y
60995 CERTIFICATE OF CERTIFIED REINSURER (CR-1) 623 kb 01/05/2016 Y