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.
- 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)
- 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)
Admissions forms (FAQ)
- Checklist Instructions
- Affidavit: Certificate of Compliance with Advertising Rules
- Application to Renew Certificate of Authority (MO 375-0079)
- Authorized Reinsurers 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 & 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
Annual filings
- 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)
Bail bond and surety recovery agents (FAQ)
- 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)
Captive insurance 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
Continuing education
- Missouri Fraud Reporting Requirements and Fraud Investigation Report Form for Insurers
Consumer fraud
- Certificate of Registration Application for Utilization Review Agents (MO 375-0049)
- Checklists
- HMO Access Plan Instructions
- HMO Credentialing
HMO/managed care
- 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
- Medigap (Medicare supplement) rate filing document: Right click to "Save Target As" for either Excel version 2007 or Excel version 2003.
Note: The above alternative Medigap rate filing documents are provided by DIFP as a courtesy for insurance companies to use when filing required Medigap rates. The alternative document has been updated to reflect recent changes in the Medicare program. DIFP will be pursuing the official regulatory changes needed to formally update “MO 375-0065,” but will accept this alternative version until such time as the necessary formal changes to 20 CSR 400-3.650 are made. Please contact the Medigap rate analyst in the Life and Healthcare Section at 573-751-3365 if you have any questions or concerns.
Medigap OUT-OF-DATE rate filing document (MO 375-0065) - Long-term care rate filing document | Excel (right click to "Save Target As")
- Life Care Facilities Statutes
- Life Care Facility Application
- Life Care Facility Checklist
Life and health forms
Life and health rate filing documents
Life care facilities
- 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
Long-term care partnership 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)
Portable electronics insurance forms
- 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 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
Producer forms (FAQ)
- NAIC Transmittal Document (TD-1)
Property and casualty forms
- Calculation of Loss Cost Multiplier (Exhibit B)
- Expense Constant Supplement (Exhibit C)
- Rate Filing Form (Exhibit A)
Property and casualty rate filings
- 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)
Public adjuster forms
- Regulation 20 CSR 700-7.100
- Reinsurance Intermediary Application
- Statute 375.1110 to 1140
Reinsurance intermediary forms
- Bond of Service Contract Provider (MO 375-0594)
- Guaranty of Service Contract Obligations (MO 375-0593)
Service contract forms
- 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 375-059
- Motor Vehicle Extended Service Contract Producer forms:
- Motor Vehicle Extended Service Contract Producer License — MO 375-0852
- Motor Vehicle Extended Service Contract Business Entity Producer License — MO 375-0853
- Change of Business Entity Producer Status — MO 375-0087
- Change of Producer Status — MO 375-0085
- 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)
Statistics
- 2012 Insurance Producers Report
- 2013 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
Tax Forms (FAQ)
- 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)
Third party administrators
- 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
Title
- Vehicle Protection Product Registration (375-0686)
Vehicle protection product forms
- 2012 Self-Insured Tax Return (Table 1)
- 2012 Self-Insured Instructions
- 2012 Group Instructions
- 2012 Group Form
- Diskette Form (Instructions)
- Independent Rate Filing Form (Exhibit A)
- Limited Liability Company Exclusion Endorsements
- Rate Development Summary Form (Exhibit B)
- Second Injury Fund Surcharge Forms