DELEG - Michigan-Specific Application Checklist and Forms

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Michigan-Specific Application Checklist and Forms

UNIFORM CERTIFICATE OF AUTHORITY APPLICATION (UCAA)
STATE-SPECIFIC APPLICATION CHECKLIST

The state specific application checklist is intended to help you assemble a complete Uniform Certificate of Authority Application (UCAA). The UCAA application is to be used for all entities applying for licensure, including life & health, property & casualty, surplus lines, fraternal, and title insurers. Please be sure to complete the state specific checklist prior to submitting your application for review. In the event some of the required documents would not apply to the types of entity, please indicate with N/A. The completed state specific checklist should be attached to the top of your state specific filings submitted with the UCAA.

Checklist	Required Filing	UCAA Primary	UCAA Expansion	Form Source	Notes
	Articles of Incorporation (FIS 0169)	1	xxx	State	A
	Capitalization (newly formed insurers only): Stock - Stock subscription agreement, stock certificate and letter from the OFIR Conduct Review and Securities Division Mutual - Surplus contribution agreement and certificate.	1	xxx	Company	B
	Qualifying Assets under Section 901(1) of the Michigan Insurance Code: Fire and Casualty and Surplus Lines Insurers (FIS 0076) Title Insurers (FIS 0077) Fraternal Benefit Society (FIS 0079) Life, Accident and Health Insurers (FIS 0081) Non-Insurance Entity (FIS 0082)	1	xxx	State	C

Notes:

A	Articles of incorporation for a domestic application must contain information required by Section 5008 of the Michigan Insurance Code, MCLA 500.5008, MSA 24.15008. The Articles of Incorporation must be submitted in triplicate and contain original signatures of incorporators on all three copies. Additionally, a $25 review fee must be paid to the Attorney General.
B	Applications for newly formed domestic insurers must include information regarding the initial capitalization. Stock insurers must provide the stock subscription agreement, stock certificate and letter from the OFIR Conduct Review and Securities Division, indicating that the sale and issuance of securities complies with the Michigan Uniform Securities Act. Mutual insurers must provide the surplus contribution agreement and surplus contribution certificate.
C	Use forms applicable to the type of company submitting application. Forms and Instructions are available on the Office of Financial and Insurance Regulation Web site.


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