Forms

The forms are in PDF format. You will need Adobe Acrobat Reader to view them. If you cannot read Excel spreadsheets, download Microsoft Excel Viewer. Check our filings section for instructions on how to make new forms filings.

Admissions Life and health Service contract
Annual filings Long-term care partnership Statistics
Bail bond and surety recovery agents Portable electronics insurance Tax
Captive insurance Producer Third party administrators
Continuing education Property and casualty Title
Consumer fraud Public adjuster Vehicle protection product
HMO/managed care Reinsurance intermediary Workers' compensation

Admissions forms (FAQ)

Advertising Compliance Form
Application for Approval to write Excess and Surplus Lines Insurance (MO 375-0474)
Application for Registration as a Purchasing Group (MO 375-0030)
Application for Registration as a Risk Retention Group (MO 375-0029)
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 (MO 375-0584)
Managing General Agent Contract (MO 375-0038)
Uniform Certificate of Authority Application (from the NAIC)

Annual filings forms

Checklist Instructions
Affidavit: Certificate of Compliance with Advertising Rules
Application to Renew Certificate of Authority (MO 375-0079)
Reinsurer Checklist
Certificate of Valuation (MO 375-0420)
Fair Plan Checklist
Fraternal Societies Checklist
Health Entities, Prepaid Dental Checklist
Life, Accident and Health Insurers Checklist
Missouri Mutual Annual Statement Instructions
Notification of Insurer/Trust Agreement (MO 375-1684)
Property and Casualty Insurers Checklist
Third Party Administrator Affidavit
Title Companies Checklist
Statement of Basket Clause for Life and Health (MO 375-0076)
Statement of Basket Clause for Property and Casualty (MO 375-0097)
Supplement to Annual Statement - Fees Between Insurers and Affiliates

Bail bond and surety recovery agents forms (FAQ)

Approved Initial Basic Training Providers
Bail Bond Agent, General Bail Bond Agent, and Surety Recovery Agent Continuing Education Certification Summary (MO 375-0107)
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)
General Bail Bond Agent Acknowledgement of Assignment (MO 375-0527)

General Bail Bond Agent Assignment (MO 375-0525)

Initial Basic Training Application          
 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)

Captive insurance forms

Actuary application (375-0598)
Captive application for admission (375-0597)
Captive Premium Tax Return (375-0599)
Independent CPA application (375-0596)
Irrevocable Letter of Credit (MO 375-0591)

Continuing education forms

BAIL BOND
Bail Bond Agent, General Bail Bond Agent, and Surety Recovery Agent Affidavit of Exam Proctor (MO 375-0108)
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 Continuing Education Provider Application for Course Approval (MO 375-0109)
PROVIDERS
Note: Producers should use the forms in the Producers list to report continuing education courses taken.
Affidavit of Exam Proctor (MO 375-0102)
CE Providers - Agent/Producer
Continuing Education Certificate of Course Completion (MO 375-0092)   (Form to be completed by course provider only)
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 MS Excel icon

Consumer fraud form

Missouri Fraud Reporting Requirements and Fraud Investigation Report Form for Insurers

HMO/managed care forms

Certificate of Registration Application for Utilization Review Agents (MO 375-0049)
Checklists
HMO Access Plan Instructions
HMO Credentialing

Life and health forms

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)
Certification of Access to Providers for Treatment of Mental Health Conditions (20 CSR 400 - 2.165)
Checklists

Life and health rate filing documents

Medigap (Medicare supplement) rate filing document: Right click to "Save Target As" for either Excel version 2007 or Excel version 2003.

Long-term care rate filing document | Excel (right click to "Save Target As")

Life care facilities

Life Care Facilities Statutes
Life Care Facility Application
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

Portable electronics insurance forms

Portable electronics insurance application (vendor with 10 or fewer locations) (MO 375-0851)
Portable electronics insurance application (vendor with more than 10 locations) (MO 375-0868)

 

Producer forms (FAQ)

1033 Waiver Application Form
Change of Business Entity Producer Status (MO 375-0087)
Change of Organizational Credit Business Entity Status (MO 375-0099)
Change of Producer Status (MO 375-0085)
Continuing Education Certification Summary (MO 375-0091)
Electronic Address Change
Electronic Resident/Non-Resident Licensing and Renewal
Missouri Uniform Application for Public Adjuster, Public Adjuster Soliciter, or Surplus Lines (MO 375-0111)
Organizational Credit Business Entity Application (MO 375-0096)
Self-Procured Insurance Tax Report--Appendix 4 (MO 375-0498)
Uniform Application for Business Entity Insurance License Renewal/Continuation
Uniform Application for Individual Producer License Renewal/Continuation
Uniform Application for Non-Resident Business Entity License Registration
Uniform Application for Non-Resident Individual Producer License
Uniform Application for Resident Business Entity License/Registration
Uniform Application for Resident Individual Insurance Producer License

Property and casualty forms

NAIC Transmittal Document (TD-1)

Property and casualty rate filings

Calculation of Loss Cost Multiplier (Exhibit B)
Expense Constant Supplement (Exhibit C)
Rate Filing Form (Exhibit A)

Public adjuster forms

Change of Public Adjuster Solictor Status (375-0070)
Change of Public Adjuster Status (MO 375-0067)
Missouri Uniform Application for Public Adjuster, Public Adjuster Soliciter, or Surplus Lines (MO 375-0111)
Public Adjuster Bond (MO 375-0033)

Reinsurance intermediary forms

Regulation 20 CSR 700-7.100
Reinsurance Intermediary Application
Statute 375.1110 to 1140

Service contract forms

Bond of Service Contract Provider (MO 375-0594)
Guaranty of Service Contract Obligations (MO 375-0593)
Service Contract Provider Registration (MO 375-0586)
Motor Vehicle Extended Service Contract Provider forms:
  • Motor Vehicle Extended Service Contract Provider Registration — MO 375-0676s
  • Bond of Motor Vehicle Service Contract Provider — MO 375-0594
  • Guaranty of Motor Vehicle Service Contract Obligations — MO 375-0592
Motor Vehicle Extended Service Contract Producer forms:
  • Motor Vehicle Extended Service Contract Producer License — MO 375-0852
  • Motor Vehicle Extended Service Contract Producer Renewal — MO 375-0890
  • Motor Vehicle Extended Service Contract Business Entity Producer License  — MO 375-0853
  • Motor Vehicle Extended Service Contract Business Entity Producer License Renewal — MO 375-0912
  • Change of Business Entity Producer Status — MO 375-0087
  • Change of Producer Status — MO 375-0085

Statistics forms

Annual Statement Supplement (MO 375-1802(Instructions)
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) (Instructions)
Online Form Filing
Online Filing Instructions
Medical ProfLiability User Guide
Medicare Supplement Insurance Experience Report (MO 375-0307)
Missouri Commercial Liability Profitability Report (MO 375-0359) (Instructions) and Commercial Liability Closed and Outstanding Claim Form
Page 19 Supplement to Annual Statement (MO 375-0381(Instructions)
Products Liability Closed Claim Report (MO 375-1663)
Products Liability Summary Report Form
Real Estate Malpractice Claim Report (MO 375-1661)

Tax forms (FAQ)

2013 Insurance Producers Report
2014 Quarterly Administrative Surcharge Report Form
Casualty Insurance Companies (MO 375-0409)
Chapter 380 Missouri Mutual Companies (MO 375-0429)
Life Insurance Companies (MO 375-0411)
Prior Year Tax Information

Third party administrator forms

Administrator Application (MO 375-1685)
Biographical Affidavit (MO 375-0536)
Bond of Third Party Administrator (MO 375-1811)
Notification of Insurer/Trust Agreement (MO 375-1684)

TPA Questionnaire (MO 375-0083)

Title forms

Business Entity Application (UA-BEP)
Individual Application (UA-IP)
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

Vehicle protection product forms

Vehicle Protection Product Registration (375-0686)

Workers' compensation forms MS Excel icon

2013 Self-Insured Tax Return (Table 1)
2013 Table 1 Instructions
Self Insured Group Instructions
2013 Group Form
Self Insured Workers' Compensation Filing User Guide
What is Individual Self Insurance Individual?
Self Insured Workers' Compensation (FAQ)
What is Group Trust Self Insurance?
Group and Trust Self Insured Workers' Compensation (FAQ)
Independent Rate Filing Form (Exhibit A)
Limited Liability Company Exclusion Endorsements
Rate Development Summary Form (Exhibit B)
Second Injury Fund Surcharge Forms