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Accredited Reinsurer

  • FIS 0174 PDF iconAccredited or Trusteed Reinsurer Certificate of Assuming Insurer (AR-1 Form)

Education Forms

Captive Insurance Forms

Financial Filing Forms

Foreign Risk Retention Group Forms

  • Instructions PDF iconFor Application for Registration
  • FIS 0260Risk Retention Group Premium and Tax is now filed electronically through NAIC OPTins
  • FIS 0233 PDF iconApplication for Foreign Risk Retention Group Registration
  • FIS 0234 PDF iconConsent to Service - Foreign Risk Retention Group
  • FIS 0235 PDF iconForeign Risk Retention Group Registration Fee Card
  • FIS 0361 PDF iconAffiliate Statement
  • FIS 0364 PDF iconReport of Operations

HMO/AFDS - Application for Licensure and Forms

Insurance Licensing Forms

Insurance Forms

  • FIS 0066 PDF iconAmendment or Restatement of Michigan Articles of Incorporation Form and Checklist
  • FIS 0144 PDF iconRequest for Determination of Exemption from Requalification Form
  • FIS 0169 PDF iconArticles of Incorporation
  • FIS 0170 PDF iconMichigan Auto Certification
  • FIS 0171 PDF iconReport of Insurers in the Holding Company
  • FIS 0278 PDF iconMedicaid Clean Claim Report
  • FIS 0279 PDF iconAnnual Notice of Medicaid Claims Defects
  • FIS 0284 PDF iconClean Claim Report
  • FIS 0308 PDF iconReport of Multiple Medicare Supplement Coverage in Force for Michigan Residents
  • FIS 0318 PDF iconComplaint and Grievance Summary for Health Carriers. FIS 319 was merged into FIS 0318.
  • FIS 0376 PDF iconFire Insurance Withholding Program - Enrollment Requirements
  • FIS 0378 PDF iconAuto Insurance Fire Loss - Enrollment Requirements
  • FIS 0425 PDF iconOath of Director of a Michigan Domestic Insurer
  • FIS 0810 PDF iconApplication for Authority to Purchase Discretionary Group Life Insurance
  • FIS 0983 PDF iconLong-Term Care Insurance Annual Sales Report

Insurance Holding Company Forms

  • Instructions
  • Form A PDF iconStatement Regarding the Acquisition of Control of or Merger with a Domestic Insurer
  • Form B PDF iconInsurance Holding Company System Annual Registration Statement
  • Form C PDF iconSummary of Registration Statement
  • Form D PDF iconPrior Notice of a Transaction

Multiple Employer Welfare Arrangements

Premium Finance Company Forms

  • FIS 0852 PDF iconInstructions for Application for Licensure
  • FIS 0853 PDF iconPremium Finance Company License Fee Card
  • FIS 0854 PDF iconAnnual Statement for Insurance Premium Finance Company
  • FIS 0855 PDF iconPremium Finance Company Balance Sheet
  • FIS 0856 PDF iconApplication For Insurance Premium Finance Company License
  • FIS 0857 PDF iconStatement of Owners, Officers, and Directors of a Premium Finance Company
  • FIS 0858 PDF iconInsurance Premium Finance Company Corporate Surety Bond

Public Employer Pooled Plan Forms

Purchasing Group Forms

  • FIS 0359 PDF iconPurchasing Group Application for Registration
  • FIS 0255Report of Insurance Purchased From an Unauthorized Insurer is now filed electronically through NAIC OPTins. One-time filers may use FIS 0255.
  • FIS 0362 PDF iconAnnual Renewal Report for Purchasing Groups
  • FIS 0363 PDF iconChange in Registration for Purchasing Groups
  • FIS 0364 PDF iconReport of Operations
  • FIS 0365 PDF iconConsent to Service - Purchasing Groups

Reinsurance Intermediary Forms

  • FIS 0845 PDF iconApplication for Reinsurance Intermediary Manager
  • FIS 2274 PDF iconApplication for Reinsurance Intermediary Broker
  • FIS 0846 PDF iconConsent to Service - Non-Resident Reinsurance Intermediary Manager or Broker

Self-Insurance (Auto - formerly administered by Secretary of State)

  • On January 1, 2013, the Department of Insurance and Financial Services (DIFS) assumed responsibility for the licensing and administration of the motor vehicle self-insurance program in accordance with Public Act No. 204 of 2012.
  • Application for Self-Insurance Checklist PDF icon
  • FIS 2271 PDF iconApplication for Self-Insurance Certificate

Surplus Lines Insurer

  • FIS 2260 PDF iconApplication for Verifying Eligibility as Surplus Lines Insurer

Surplus Lines Tax Forms

  • FIS 0255Report of Insurance Purchased From an Unauthorized Insurer is now filed electronically through NAIC OPTins. One-time filers may use FIS 0255.
  • FIS 0269Report of Transaction with an Unauthorized Insurer Not Recognized as Eligible is now filed electronically through NAIC OPTins
  • FIS 0270Surplus Lines Agent Semi-Annual Report of Michigan Premiums and Tax is now filed electronically through NAIC OPTins

Third Party Administrator Forms

  • FIS 0849 PDF iconThird Party Administrator Application Checklist
  • FIS 0850 PDF iconFinancial Statement for Third Party Administrators
  • FIS 0860 PDF iconThird Party Administrator Consent to Service
  • FIS 0861 PDF iconThird Party Administrator Application for Certificate of Authority
  • FIS 0862 PDF iconThird Party Administrator Affiliation Statement
  • FIS 0863 PDF iconFee Processing Card for Third Party Administrators
  • FIS 0865 PDF iconTPA Jurat Page for Annual Renewal

Uniform Certificate of Authority Application