Company Licensing Forms

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Application Forms

Acquisition of or Merger with Louisiana Domiciled Insurer

Captive Insurer (Louisiana Domestic)

Dental Referral Plan

Discount Medical Plan Organization Application

Dissolution of a Louisiana Domiciled Insurer

Home Service Contract Provider

Independent Review Organization

Louisiana Domestic Insurer

Medical Necessity Review Organization (previously known as Utilization Review Agent)

Motor Vehicle Rental Insurers Limited License

Professional Employer Organization

Property Residual Value Insurer (GAP)

Risk Purchasing Group

Risk Purchasing Group Renewal Application

Surplus Lines Insurer

Third Party Administrator

Uniform Certificate of Authority Application (UCAA) Louisiana State Specific Package

Vehicle Mechanical Breakdown Insurer

Viatical Investment Agent

Viatical Settlement Broker

Viatical Settlement Provider

Withdrawal of a Foreign or Alien Insurer Licensed in Louisiana

 

Annual Report Forms

Third Party Administrator Annual Report

Viatical Investment Agent Annual Report

Viatical Settlement Broker Annual Report

Viatical Settlement Provider Annual Report

 

Other Documents

Affidavit of Publication of Public Notice

List of Third Party Vendors for Background Investigative Reports

Affidavit of Loss of Original Certificate of Authority

Agreement to Comply with Rates, Rules and Regulations

Directors Acceptance of Trust

NAIC Biographical Affidavit Form

NAIC Health Financial Blank (for health maintenance organization applications)

Oath of Liability Application

Oath of Officer

Regulation 66: Requirements for Officers, Directors, and Trustees of Domestic Regulated Entities

Retaliatory Statement

Sample of Phone Contact Inquiry (Excel)

Sample Ownership Chart

TPA Notice of Contract Form