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Insurance

Accredited Reinsurer

FIS 0174

Accredited or Trusteed Reinsurer Certificate of Assuming Insurer (AR-1 Form)

Auto Insurance Utilization Review Forms

FIS 2356

Auto Insurance Utilization Review Provider Appeal Request

FIS 2358

Auto Insurance Utilization Review Insurer Annual Report

FIS 2361

Auto Insurance Utilization Review Insurer Reply to Provider Appeal

FIS 2362

Application for Unconditional Certification of Auto Insurance Utilization Review Program

FIS 2364

Application for Designation as Freestanding Rehabilitation Facility

FIS 2376

Auto Insurance Utilization Review Provider Attestation

Cybersecurity Event

FIS 2359

Notice of Cybersecurity Event

FIS 2360

Information Security Program Annual Certification

FIS 2378

Domestic Insurer Exemption Certification

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

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
Risk 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

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 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

FIS 2345

Certificate of Division

FIS 2367

Insurance Agent (Producer) Disclosure for Annuities

FIS 2377

Certification Statement of Prepaid, Noncancelable, Auto Insurance Policy

FIS 2378

Domestic Insurer Exemption Certification

Insurance Holding Company Forms

Form A

Statement Regarding the Acquisition of Control of or Merger with a Domestic Insurer

Form B

Insurance Holding Company System Annual Registration Statement

Form C

Summary of Registration Statement

Form D

Prior Notice of a Transaction

Form F

Enterprise Risk Report

Insurance Licensing Forms

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

FIS 2367

Insurance Agent (Producer) Disclosure for Annuities

Multiple Employer Welfare Arrangements

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

FIS 2379

Prior Authorization Practices and Experience Checklist

Public Employer Pooled Plan Forms

Public Employer Pooled Plan (Pool) application filing package

Includes all forms and instructions except Exhibit 1

Purchasing Group Forms

Report 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

Reinsurance Intermediary Forms

FIS 0845

Application for Reinsurance Intermediary Manager

FIS 0846

Consent to Service - Non-Resident Reinsurance Intermediary Manager or Broker

FIS 2274

Application for Reinsurance Intermediary Broker

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

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

Report of Insurance Purchased From an Unauthorized Insurer is now filed electronically through NAIC OPTins. One-time filers may use FIS 0255.
Report of Transaction with an Unauthorized Insurer Not Recognized as Eligible is now filed electronically through NAIC OPTins
Surplus 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