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Admissions Forms (FAQs)

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)
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) (69.9 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

General Instructions (PDF, 42 KB)

Assessment Companies Checklist (PDF, 29 KB)

Fair Plan Checklist(PDF, 28 KB)

Fraternal Societies (PDF, 67 KB)

Health Entities Checklist (PDF, 62 KB)

Life, Accident and Health Insurers Checklist (PDF, 76 KB)

Prepaid Dental Checklist (PDF, 85 KB)

Property & Casualty Insurers Checklist (PDF, 74 KB)

Authorized Reinsurers Checklist(PDF, 28 KB)

Title Companies Checklist (PDF, 51 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)

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)

Complaints

Provider Complaint Form--for prompt payment of health claims (35 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)

Continuing Education Course Provider Electronic Filing (Excel) Revised 4/14/08 (130 Kb)
     (Right-click on Excel link to save file to your computer)

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) (46 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 Continuing Education Certification Summary (MO 375-0107) (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)

Standardized Credentialling Form (107 Kb) | Excel | Zipped Excel format

• Use of Kansas's Standard Credentialing Application form remains permissible, effective 4-1-07 through 4-1-08.  Use of Kansas's form shall not remain permissible after 4-1-08, pending re-review of that form.  Please see 20 CSR 400-7.180 regarding the permissibility of forms other than the Missouri Standardized Credentialing Form.
• Important note:  The Kansas form has been scheduled for modification and revision, effective 6-1-07.  In spite of the differences between the Missouri and Kansas forms, the majority of HMOs that responded to our request for input on this matter have indicated they prefer to accept the new Kansas form if it’s submitted by a KS provider.  Because “carriers shall accept any form approved by the director for credentialing purposes, and shall not require a Missouri health care professional to use any particular approved form to the exclusion of any other approved form”, providers being credentialed for a MO HMO cannot be asked to complete more than one form.  Therefore all HMOs and their credentialing agents must be prepared to accept the new KS/CAQH form. Missouri is considering making changes to the MO SCF similar to the KS changes.  If you want more information on the change process in Missouri, please contact Molly White.  See contact information below.
• At this time, all HMOs and their credentialing agents are required to accept the Missouri or Kansas Standardized Credentialing Form (SCF). HMOs and their credentialing agents that develop their own electronic systems for gathering and storing credentialing data MUST also accept electronic or paper submission of the SCF.  Please refer to current law at section 354.442.1(15), RSMo, and 20 CSR 400-7.180.

  Please direct any comments, questions or concerns to:

       Molly White, MHA

       Supervisor, Managed Care Section

       (573)526-4106

       Molly.White@insurance.mo.gov

• 2004 Physician Credentialing Guide The Missouri State Medical Association created a brief guide to filling out the Standardized Credentialing Form. Their guide was developed for physicians, but is pertinent to any practitioner.

 

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

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

HMO Access Plan Instructions (MS Office version (self-extracting zip file)

Life and Health Forms

Checklists

Transmittal Document (TD-1) (9 Kb)

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

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)

Surplus Lines Filing Report--Appendix 1 (MO 375-0481) (65.6 Kb)

Surplus Lines Declination Detail (25.2 Kb)

Surplus Lines Licensee's Tax Report--Appendix 3 (MO 375-0499) (136 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)

Reinsurance Intermediary Forms

Reinsurance Intermediary Application (57 Kb)

Regulation 20 CSR 700-7.100

Statute 375.1110 to 1140

Service Contract Forms

Bond of Motor Vehicle Service Contract Provider (MO 375-0595) (41.8 KB)
Guaranty of Motor Vehicle Service Contract Obligations (MO 375-0592) updated form available soon
Bond of Service Contract Provider (MO 375-0594) (49.1 KB)
Guaranty of Service Contract Obligations (MO 375-0593)(48 KB)
Instructions for Motor Vehicle Extended Service Contract Provider Registration (MO 375-0585) (79.5 KB)
Instructions for Service Contract Provider Registration (MO 375-0586) (232 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) (50 Kb)

Instructions for MO 365-1802

Page 20 Supplement to Annual Statement (MO 375-0381) (48 Kb)

Instructions for MO 375-0381

Tax Forms (FAQs)

Casualty Insurance Companies ( MO 375-0409) (118 Kb)

Life Insurance Companies ( MO 375-0411) (115 Kb)

Chapter 380 Missouri Mutual Companies ( MO 375-0429) (102 Kb)

2007 Quarterly Administrative Surcharge Report Form (150 Kb)

2008 Quarterly Administrative Surcharge Report Form (94 Kb)
2007 Insurance Producers Report (44 Kb)
2006 Insurance Producers Report (44 Kb)

2005 Insurance Producers Report (36 Kb)

 

Prior Year Tax Forms

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

Verification of the Examination of Title (Exhibit A) (51 Kb)

Affidavit (Exhibit B) (29Kb)

Annual Registration of Title Plant (Exhibit C) (54 Kb)
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   (10 KB)
T-4 Affiliated Business Disclosure  (10 KB)
T-5 Affiliated Business Arrangement Report (11 KB)
T-7 Uniform Premium (Risk Rate) Report (31 KB)
T-8 Seller's Closing Protection Letter  (16KB)
alt T-8 Seller's Closing Protection Letter (16 KB)
T-9 Seller's Closing Protection Letter (18 KB)
alt T-9 Seller's Closing Protection Letter (18 KB)
T-10 Verification of Examination of Title (11 KB)
T-11 Examination Location Affidavit (14 KB)
T-12 Annual Title Plant Registration (18 KB)
Individual Application (UA-IP)
Business Entity Application (UA-BEP)

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)