Forms

The forms are available in Acrobat format. They vary in size from 5 KB to 1.02 MB. You will need Adobe Acrobat Reader to view these forms.

If you cannot read Excel spreadsheets, download the Microsoft Excel Viewer.

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)

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

Authorized Reinsurer Application and Information (MO 375-1793)

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

Annual Filings

Filing Instructions

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

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

Certificate of Valuation (MO 375-0420)

Affidavit: Certificate of Compliance with Advertising Rules

Assessment Companies Checklist

Fair Plan Checklist

Fraternal Societies Checklist

Health Entities, Prepaid Dental Checklist

Life, Accident and Health Insurers Checklist

Property & Casualty Insurers Checklist

Authorized Reinsurers Checklist

Title Companies Checklist

Title Premium Reserve (MO 375-0418)

Third-Party Administrator Affidavit

Statement of Basket Clause Investments

Statement of Basket Clause for P&C (MO 375-0097)

Supplement to Annual Statement - Fees Between Insurers and Affiliates

          Missouri Mutual Annual Statement Instructions

Bail Bond and Surety Recovery Agents

Frequently Asked Questions

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

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

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

Acknowledgement of Assignment (MO 375-0527)

Change of Bail Bond Status (MO 375-0031)

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

Change of Surety Recovery Status (MO 375-0103)

General Bail Bond Affidavit (MO 375-0034)

Approved Initial Basic Training Providers

Initial Basic Training Application

Captive Insurance Forms

Irrevocable Letter of Credit (MO 375-0591)

Actuary application (375-0598)

Independent CPA application (375-0596)

?aptive application for admission (375-0597)

          Captive Premium Tax Return (375-0599)

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)

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)(Form to be completed by course provider only)

CE Providers - Agent/Producer

Affidavit of Exam Proctor (MO 375-0102)

• Bail Bond

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

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

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

Consumer Fraud

Fraud Investigation Report for Insurers (MO 375-1785)

On-line Fraud Investigation Report for Insurers

Missouri Fraud Reporting Requirements For Insurers

HMO/Managed Care

Checklists

Compliance Certificate for Health Care Provider Contracts

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

HMO Access Plan Instructions

HMO Credentialing

Life and Health Forms

Checklists

Transmittal Document (TD-1)

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

Actuarial Certification--Small Employers Health Insurance Availability Act

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

Life Care Facilities

Life Care Facility Application

Life Care Facilities Statutes

Life Care Facility Checklist

Long-Term Care Partnership Forms

LTC-1 Notice to Applicant Regarding Replacement Form

LTC-2 Notice to Applicant Regarding Replacement for DR Form

LTC-3 Outline of Coverage Form

LTC-4 Long Term Care Partnership Exchange Notification Form

LTC-5 Long Term Care Partnership Program Policy Certification Form

LTC-6 Long Term Care Insurance Partnership Disclosure Notice

LTC-7 Long Term Care Insurance Partnership Delivery Notice

LTC-A Rescission Reporting Form

LTC-B Personal Worksheet Form

LTC-C Things You Should Know Before You Buy Form

LTC-D Suitability Letter Form

LTC-E Claims Denial Reporting Form

LTC-F Potential Rate Increase Form

LTC-G Replacement and Lapse Report Form

Property and Casualty Forms

Transmittal Document (TD-2)

P&C Rate Filings

Rate Filing Form (Exhibit A)

Calculation of Loss Cost Multiplier (Exhibit B)

Expense Constant Supplement (Exhibit C)

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)

Continuing Education Certification Summary (MO 375-0091)

Change of Producer Status (MO 375-0085)

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

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

Public Adjuster Bond (MO 375-0033)
Change of Public Adjuster Status (MO 375-0067)
Change of Public Adjuster Solictor Status (375-0070)

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

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

1033 Waiver Application Form

Reinsurance Intermediary Forms

Reinsurance Intermediary Application

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)
Instructions for Motor Vehicle Extended Service Contract Provider Renewal (MO 375-0676)
Guaranty of Motor Vehicle Service Contract Obligation (MO 375-0592)
Bond of Motor Vehicle Service Contract Provider (MO 375-0595)
Instructions for Service Contract Provider Initial Registration (MO 375-0586)
Instructions for Service Contract Provider Renewal (MO 375-0675)
Guaranty of Service Contract Obligations (MO 375-0593)
Bond of Service Contract Provider (MO 375-0594)

Statistics

Dram Shop Liability Insurance Premium and Loss Report (MO 375-0100) Instructions for reporting Dram Shop Liability

Legal Malpractice Claim Report (MO 375-1662)

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

Medicare Supplement Insurance Experience Report (MO 375-0307)

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

Commercial Liability Closed and Outstanding Claim Form

Instructions for Completing MO 375-0359

Products Liability Closed Claim Report (MO 375-1663)

Real Estate Malpractice Claim Report (MO 375-1661)

Annual Statement Supplement (MO 375-1802)

Instructions for Completing MO 375-1802

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

Instructions for Completing MO 375-0381

Tax Forms (FAQs)

Casualty Insurance Companies (MO 375-0409)

Life Insurance Companies (MO 375-0411)

Chapter 380 Missouri Mutual Companies (MO 375-0429)

2009 Insurance Producers Report

2010 Quarterly Administrative Surcharge Report Form

Prior Year Tax Information

Third-Party Administrators

Administrator Application (MO 375-1685)

Biographical Affidavit (MO 375-0536)

Bond of Third Party Administrator (MO 375-1811)

TPA Questionnaire (MO 375-0083)

Title

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

Vehicle Protection Product Forms

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

Workers Compensation

Diskette Form (5 Kb) (Instructions)

Independent Rate Filing Form (Exhibit A)

Rate Development Summary Form (Exhibit B)

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

Limited Liability Company Exclusion Endorsements

Self-Insured Tax Return (Table 1)