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Accredited Reinsurer
- FIS 0174
Accredited or Trusteed Reinsurer Certificate of Assuming Insurer (AR-1 Form)
Captive Insurance Forms
- Annual Reporting for Captive Insurance Companies
- Captive Insurance Company Administrative Rules (Effective June 25, 2015)
- Captive Manager Approval Listing
- Chapter 46 of the Michigan Insurance Code
- Chapter 47 of the Michigan Insurance Code
- Chapter 48 of the Michigan Insurance Code
- FIS 2214 Captive Insurer Application Includes supporting forms and instructions to make application for a Captive Insurer limited certificate of authority.
- FIS 2308 Application for Placement on Approved Captive Insurer Management List
- Michigan Domestic Captive Insurance Companies
Education Forms
- FIS 0406 and FIS 0407
Application for Continuing Education Course/Provider Approval and Payment Sheet
- FIS 0409
Application for Insurance Prelicensing Education Provider/Course Approval
- FIS 2327
Application for Insurance Education Instructor Approval
- FIS 2331
Insurance Education Instructor Association Request
- NAIC Uniform Continuing Education Reciprocity Course Filing Form (CER)
Financial Filing Forms
- Financial Statement Instruction Booklets and Forms
UPDATED 1/22/2018-Use this link for complete form and instruction packets.
- Checklists of Financial Form Filings
- Health Maintenance Organizations/Alternative Financing and Delivery Systems/Dental Service Corporations
- 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
Foreign Risk Retention Group Forms
- FIS 0233 Application for Foreign Risk Retention Group Registration
- FIS 0234 Foreign Risk Retention Group Consent to Service
- FIS 0235 Fee Processing Card for Foreign Risk Retention Groups
- FIS 0260Risk Retention Group Premium and Tax is now filed electronically through NAIC OPTins
- FIS 0361 Affiliate Statement
- FIS 0364 Report of Operations
- Instructions For Application for Registration
HMO/AFDS - Application for Licensure and Forms
- FIS 0273
HMO/AFDS Application for Certificate of Authority
- FIS 0274
Appointment for Authorized Representative
- FIS 0284
Model Trust Indenture
- FIS 0285
Deposit Instructions (HMO)
- HMO/AFDS Application Instructions, Exhibits and Attachments
- Michigan Network Adequacy Guidance - UPDATED 05/07/18
- Michigan Network Data Template Instructions - UPDATED 05/07/18
- Michigan Network Data Template (FIS 2273) - UPDATED 04/18/18
- Network Adequacy - Michigan Service Area Maps
Insurance Forms
- FIS 0066
Amendment or Restatement of Michigan Articles of Incorporation Form and Checklist
- FIS 0144
Request for Determination of Exemption from Requalification Form
- FIS 0169
Articles of Incorporation
- FIS 0170
Michigan Auto Certification
- FIS 0171
Report of Insurers in the Holding Company
- FIS 0278
Medicaid Clean Claim Report
- FIS 0279
Annual Notice of Medicaid Claims Defects
- FIS 0284
Clean Claim Report
- FIS 0308
Report of Multiple Medicare Supplement Coverage in Force for Michigan Residents
- FIS 0318
Complaint and Grievance Summary for Health Carriers. FIS 319 was merged into FIS 0318.
- FIS 0376
Fire Insurance Withholding Program - Enrollment Requirements
- FIS 0378
Auto Insurance Fire Loss - Enrollment Requirements
- FIS 0425
Oath of Director of a Michigan Domestic Insurer
- FIS 0983
Long-Term Care Insurance Annual Sales Report
- FIS 2307
Checklist for Individual and Small Group MEDICAL Plans - FORMS
- FIS 2306
Checklist for Individual and Small Group MEDICAL Plans - RATES
- FIS 2305
Checklist for Individual and Small Group STAND-ALONE DENTAL Plans - FORMS
- FIS 2304
Checklist for Individual and Small Group STAND-ALONE DENTAL Plans - RATES
- FIS 2316
MI Uniform Modification Justification Documentation form
- FIS 2313
Checklist for Individual and Small Group MEDICAL Plans - NETWORK ADEQUACY
- FIS 2314
Checklist for Individual and Small Group STAND-ALONE DENTAL Plans - NETWORK ADEQUACY
- FIS 2310
Partnership Program Notice and Long-Term Care Partnership Policy Certification Form
- FIS 2322
Property Insurance Fire Loss - Enrollment Requirements
Insurance Holding Company Forms
Insurance Licensing Forms
- Address Changes for Individual and Agency Licensees
- Application for Written Consent to Engage in the Business of Insurance
Pursuant to 18 USC Section 1033 and 1034
- Document Requests - Certification Letter, Duplicate License, License History
- Electronic Resident and Non-Resident Licensing applications
- Examination Experience Complaint
- Name Changes
- FIS 0201
Individual Insurance licensee Registration or Cancellation of DBA
- FIS 0242
Managing General AGENT or AGENCY Appointment / Cancellation
- FIS 2312
Limited Power of Attorney
- FIS 2328
Voluntary Surrender Request Form
- FIS 2329
Clearance Letter Request Form
Multiple Employer Welfare Arrangements
- MEWA Pro Forma Balance Sheet
(Exhibit 1) - MEWA application filing package includes all forms and instructions except Exhibit 1
Premium Finance Company Forms
- FIS 0852 Instructions for Application for Licensure
- FIS 0853 Premium Finance Company License Fee Card
- FIS 0854 Annual Statement for Insurance Premium Finance Company
- FIS 0855 Premium Finance Company Balance Sheet
- FIS 0856 Application for Insurance Premium Finance Company License
- FIS 0857 Statement of Owners, Officers, and Directors of a Premium Finance Company
- FIS 0858 Insurance Premium Finance Company Corporate Surety Bond
Prior Authorization Form
- FIS 2288 Prior Authorization Request Form for Prescription Drugs
Public Employer Pooled Plan Forms
- Pool Pro Forma Balance Sheet (Exhibit 1)
- Public Employer Pooled Plan (Pool) application filing package
Includes all forms and instructions except Exhibit 1
Purchasing Group 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 0359 Purchasing Group Application for Registration
- FIS 0361 Affiliate Statement
- FIS 0362 Purchasing Group Annual Renewal Report
- FIS 0363 Purchasing Group Change in Registration
- FIS 0364 Report of Operations
- FIS 0365 Purchasing Group Consent to Service
Self-Insurance (Auto - formerly administered by Secretary of State)
- Application for Self-Insurance Checklist
- FIS 2271 Application for Self-Insurance Certificate
- 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.
Surplus Lines Insurer
- FIS 2260 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 Third Party Administrator Application Checklist
- FIS 0850 Financial Statement for Third Party Administrators
- FIS 0860 Third Party Administrator Consent to Service
- FIS 0861 Third Party Administrator Application for Certificate of Authority
- FIS 0862 Third Party Administrator Affiliation Statement
- FIS 0863 Fee Processing Card for Third Party Administrators
- FIS 0865 Third Party Administrator Jurat Page for Annual Renewal