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Michigan-Specific Application Checklist and Forms


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.

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 LARA Securities Division
  • Mutual - Surplus contribution agreement and certificate.
1 xxx Company B

Qualifying Assets under Section 901(1) of the Michigan Insurance Code:

1 xxx State C


  1. 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.
  2. 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 LARA 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.
  3. Use forms applicable to the type of company submitting application. Forms and Instructions are available on the Department of Insurance and Financial Services website