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Accredited Reinsurer

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

Education Forms

• FIS 0406 and FIS 0407 PDF icon Application for Continuing Education Course/Provider Approval and Payment Sheet

• FIS 0409 PDF icon Application for Insurance Prelicensing Education Provider/Course Approval

• NAIC Uniform Continuing Education Reciprocity Course Filing Form (CER)

Captive Insurance Forms

• FIS 2214 Captive Insurer Application PDF icon Includes supporting forms and instructions to make application for a Captive Insurer limited certificate of authority.

• Annual Reporting for Captive Insurance Companies

Financial Filing Forms

• Financial Statement Instruction Booklets and Forms UPDATED 1/3/2014-Use this link for complete form and instruction packets.

• Life, Accident & Health Insurers/Fraternal Benefit Societies/United States Branches of Non-US Insurers

• Property and Casualty Insurers/Title Insurers/Surplus Lines Insurers/United States Branches of Non-U.S. Insurers

• Health Maintenance Organizations/Alternative Financing and Delivery Systems/Nonprofit Health Care Corporations/Dental Service Corporations

• Checklists of Financial Form Filings

Foreign Risk Retention Group Forms

• Instructions PDF icon For Application for Registration

• FIS 0260Risk Retention Group Premium and Tax is now filed electronically through NAIC OPTins

• FIS 0233 PDF icon Application for Foreign Risk Retention Group Registration

• FIS 0234 PDF icon Consent to Service - Foreign Risk Retention Group

• FIS 0235 PDF icon Foreign Risk Retention Group Registration Fee Card

• FIS 0361 PDF icon Affiliate Statement

• FIS 0364 PDF icon Report of Operations

HMO/AFDS - Application for Licensure and Forms

• 2015 Filing Requirements On and Off the Marketplace PDF icon

• Individual and Small Group Health Insurance Plans Forms Checklist Excel icon

• Individual and Small Group Health Insurance Plans Rates Checklist DOC icon

• HMO/AFDS Application Instructions, Exhibits and Attachments PDF icon

• FIS 0273 PDF icon HMO/AFDS Application for Certificate of Authority

• FIS 0274 PDF icon Appointment for Authorized Representative

• FIS 0284 PDF icon Model Trust Indenture

• FIS 0285 PDF icon Deposit Instructions (HMO)

• Michigan Network Adequacy Guidance PDF icon

• Michigan Network Data Template Instructions - UPDATED 3/26/14 PDF icon

• Michigan Network Data Template - UPDATED 3/26/14 ZIP icon

• Network Adequacy - Michigan Service Area Maps

Insurance Licensing Forms

• Electronic Resident and Non-Resident Licensing applications

• Application for Written Consent to Engage in the Business of Insurance PDF icon Pursuant to 18 USC Section 1033 and 1034

• FIS 0200 PDF icon Insurance Business Entity Affiliate Disclosure

• FIS 0201 PDF icon dba Registration

• FIS 0242 PDF icon Managing General AGENT or AGENCY Appointment / Cancellation

• FIS 0261 Insurance License Document Request

• FIS 0262 PDF icon Name change - for all licensees. Address change - must be used by agencies and may be used by individual licensees.

• Address Change Request for all individual licensees Any non-resident adjuster must have only one home state license or must use form FIS 0262 (below).

• FIS 2268 PDF icon Branch Office Registration form

• Examination Experience Complaint

Insurance Forms

• FIS 0066 PDF icon Amendment or Restatement of Michigan Articles of Incorporation Form and Checklist

• FIS 0144 PDF icon Request for Determination of Exemption from Requalification Form

• FIS 0169 PDF icon Articles of Incorporation

• FIS 0170 PDF icon Michigan Auto Certification

• FIS 0171 PDF icon Report of Insurers in the Holding Company

• FIS 0278 PDF icon Medicaid Clean Claim Report

• FIS 0279 PDF icon Annual Notice of Medicaid Claims Defects

• FIS 0284 PDF icon Clean Claim Report

• FIS 0308 PDF icon Report of Multiple Medicare Supplement Coverage in Force for Michigan Residents

• FIS 0318 PDF icon Complaint and Grievance Summary for Health Carriers. FIS 319 was merged into FIS 0318.

• FIS 0376 PDF icon Fire Insurance Withholding Program - Enrollment Requirements

• FIS 0378 PDF icon Auto Insurance Fire Loss - Enrollment Requirements

• FIS 0425 PDF icon Oath of Director of a Michigan Domestic Insurer

• FIS 0810 PDF icon Application for Authority to Purchase Discretionary Group Life Insurance

• FIS 0983 PDF icon Long-Term Care Insurance Annual Sales Report

Insurance Holding Company Forms

• Instructions

• Form A PDF icon Statement Regarding the Acquisition of Control of or Merger with a Domestic Insurer

• Form B PDF icon Insurance Holding Company System Annual Registration Statement

• Form C PDF icon Summary of Registration Statement

• Form D PDF icon Prior Notice of a Transaction

Multiple Employer Welfare Arrangements

• The MEWA application is under review and a revised version will be available soon.

• MEWA application filing package PDF icon includes all forms and instructions except Exhibit 1

• MEWA Pro Forma Balance Sheet Excel icon (Exhibit 1)

Premium Finance Company Forms

• FIS 0852 PDF icon Instructions for Application for Licensure

• FIS 0853 PDF icon Premium Finance Company License Fee Card

• FIS 0854 PDF icon Annual Statement for Insurance Premium Finance Company

• FIS 0855 PDF icon Premium Finance Company Balance Sheet

• FIS 0856 PDF icon Application For Insurance Premium Finance Company License

• FIS 0857 PDF icon Statement of Owners, Officers, and Directors of a Premium Finance Company

• FIS 0858 PDF icon Insurance Premium Finance Company Corporate Surety Bond

Public Employer Pooled Plan Forms

• Public Employer Pool Plan (Pool) application filing package PDF icon Includes all forms and instructions except Exhibit 1

• Pool Pro Forma Balance Sheet Excel icon (Exhibit 1)

Purchasing Group Forms

• FIS 0359 PDF icon Purchasing 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 icon Annual Renewal Report for Purchasing Groups

• FIS 0363 PDF icon Change in Registration for Purchasing Groups

• FIS 0364 PDF icon Report of Operations

• FIS 0365 PDF icon Consent to Service - Purchsing Groups

Reinsurance Intermediary Forms

• FIS 0845 PDF icon Application for Reinsurance Intermediary Manager

• FIS 2274 PDF icon Application for Reinsurance Intermediary Broker

• FIS 0846 PDF icon Consent 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 icon Application for Self-Insurance Certificate

Surplus Lines Insurer

• FIS 2260 PDF icon Application 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 icon Third Party Administrator Application Checklist

• FIS 0850 PDF icon Financial Statement for Third Party Administrators

• FIS 0860 PDF icon Third Party Administrator Consent to Service

• FIS 0861 PDF icon Third Party Administrator Application for Certificate of Authority

• FIS 0862 PDF icon Third Party Administrator Affiliation Statement

• FIS 0863 PDF icon Fee Processing Card for Third Party Administrators

• FIS 0865 PDF icon TPA Jurat Page for Annual Renewal

Uniform Certificate of Authority Application

• Application Form

• Michigan-Specific Application Checklist and Forms

• Schedule of Company Fees, Taxes and Deposits PDF icon

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