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Ohio Department of Insurance

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 ODI Forms
Consumer Services
INS1005Insurance Complaint Form
INS2501OSHIIP Volunteer Application
Enforcement
INS6012Enforcement Complaint Form
INS6013Agent Termination For Cause Form
NAIC Application For Written Consent To Engage In The Business Of Insurance (1033)
Financial Regulation
INS5025MEWA Certificate of Authority Application Requirements
INS7001Insurance Regulatory Information System
INS7004Application for Certificate of Authority - Fraternal Benefit Societies, Home Warranties, Mutual Protective Associations and Title Companies
INS7005Application For Certificate of Authority - P&C
INS7006Application For Certificate of Authority - Life
INS7014Ohio Automobile Insurance Plan (Auto Ins.)
INS7015Ohio Fair Plan Underwriting Association (Homeowners/property)
INS7016Ohio Fire Marshal Tax Return
INS7058Application For Certificate of Authority - MEWA'S
INS7059Instructions For Filing Annual Statement - MEWA'S
INS7062Internet & Diskette Submissions of A/S to NAIC
INS7080Profit and Loss Statement
INS7140Exhibit A Tax Credit - All Foreign & Domestic Insurers
INS7141Domestic Health Insuring Corporation Franchise Tax Form
INS7142Domestic Life Insurance Company Franchise Tax Form
INS7143Domestic Property & Casualty Franchise Tax Form
INS7144Domestic Fire Assessment Association Franchise Tax Form
INS7145Foreign Health Insuring Corporation Premium Tax Form
INS7146Foreign Life Insurance Company Premium Tax Form
INS7147Foreign Property & Casualty Premium Tax Form
INS7148Dividend Deductions For Premium Taxes - Foreign P&C Insurers
INS7150Computation of Deposits - Domestic Title Co's
INS7151Computation of Deposits - Domestic Title & Trust Co's
INS7152Computation of Deposits - Foreign Title Co's
INS7160Audited Consolidated/Combined Statutory Financial Statements
INS7166Audited Financial Statement Exemption Affidavit
INS7168Financial Disclosure Form - HIC's
INS7186Exemption Affidavit For Actuarial Opinion - Ohio Titles
INS7213Bar Coding Instructions
INS7214Domestic Fire Marshal Tax Summary Form
INS7215Foreign/Alien Tax Summary Form
INS7226Exhibit of Premiums, Enrollment and Utilization - HMO
INS7239Dividend / Distribution Notification Filing
INS7240Electronic Filing Authenticity Affidavit
INS9008Requirements for HIC Major Modification
INS9011Service Area Expansion / Ohio Department of Health
INS9032Instructions for Application for a Health Insuring Corporation Certificate of Authority
INS9089Viatical Settlement Provider Certification of Compliance for Advertisements
INS9102Authority for Release of Information for Viatical Settlement Provider Application
INS9103Viatical/Life Settlement Provider Application Approval Standards
INS9104Viatical/Life Settlement Providers Bond
INS9105Viatical/Life Settlement Provider CheckList
INS9106Viatical Settlement Provider License Application
INS9107Renewal Viatical Settlement Provider License Application
Disclosue And Authorization Concerning Background Reports
Performance Bond Form for Medicaid HICs
Fiscal
INS2010Insurer and Direct Participant/Member Bank Agreement
INS2011Book Entry Legal Deposit
INS2072Book Entry Deposit List
Fraud
INS0100Fraud Complaint Form (Company)
INS0126Fraud Complaint Form / Person
Licensing
INS3008Notification of Changes for Business Entity
INS3049Application for Pre-License School Approval
INS3052Pre-License Instructor Registration
INS3056Registration For Pre-Licensing Authorized Provider Official Approval
INS3058Pre-License School Filing Requirements
INS3059Pre-Licensing Education Financial Interest Statement
INS3177Reinsurance Intermediary Broker Lic/Letter
INS3224TPA License Application
INS3225Pre-Licensing Publisher List
INS3235License Inactivation Request
INS3236License Reactivation Request
INS3239Viatical Settlement License Application
INS3240License Surrender Form
INS3241Agent Address Change Form
INS3243Producer Application Title License
INS3244Business Entity Title License Application
INS3245Broker License - Surplus Lines Application
INS3246Request for Duplicate License
INS3248Application for Public Insurance Adjusters/Agents
INS3250Application for Managing General Agents
INS3251Surety Bail Bond Agent License Application
INS3252Business Entity Surety Bail Bond Agency License Application
INS3253Third Party Administrator Renewal Application
INS3254Clearance Letter
INS3255Surety Bail Bond Agent License Renewal Application
INS3256Business Entity Surety Bail Bond Agency License Renewal Application
INS3257Home State Certification Letter Request
INS3258Renewal Viatical Settlement Broker License Application
INS3259Pre-Licensing Education Provider Renewal Application
INS3260Notice to All Pre-License Schools Regarding Bulletins
INS3261Pre-Licensing Student Course Completion Certificate Guidelines
INS3264Suspension Reactivation
INS3266Third Party Administrator License Application Review Checklist
INS3268Business Entity Public Insurance Adjuster License Application
INS3269Viatical Broker INDIVIDUAL License Application Checklist
INS3270Viatical Broker ENTITY License Application Checklist
INS3271Surplus Lines Broker License Renewal Application For Individual
INS3272Surplus Lines Broker License Renewal Application For Business Entity
INS3276Pre-License Education Waiver Request
NAIC Uniform Non-Resident Business Entity Application
NAIC Uniform Resident Business Entity Application
Uniform Non-Resident Producer Application
Uniform Resident Agent Application
Life & Health
INS5027Application for a Certificate of Authority to Sponsor a Small Employer Health Care Alliance
INS5028Renewal Application for a Certificate of Authority to Sponsor a Small Employer Health Care Alliance
INS5033Certification of External Review Procedures
INS9108Review Requirements Checklist Viaticals Form Filing for Prior Approval
INS9109Review Requirements Checklist Life Insurance Form Filing for Prior Approval
INS9110Review Requirements Checklist Sickness and Accident Health Insurance
INS9111Review Requirements Checklist Medicare Supplements Form Filing for Prior Approval
Managed Care
INS9012Flesch Reading Ease Test
INS9014HIC Deposit & Filing Fee Schedule
INS9016HIC Provider / HCF Contract Certification Form
INS9017HIC Requirements For Publication Notice / Post Documentation
INS9019HIC Open Enrollment Summary Requirements
INS9020HIC Open Enrollment Request For Waiver / Limit
INS9021HIC Open Enrollment Filing Checklist
INS9022HIC Solicitation Review Guidelines & Checklist
INS9025Quality Assurance Programs Certification of Compliance
INS9026Utilization Review Programs Certification of Compliance
INS9027External Independent Review Process Certification of Compliance
INS9031HIC Holding Open Enrollment / Counties Packet
INS9036Rate Filing Guidelines
INS9060Form of Required $250,000.00 Deposit
INS9071Guaranty
INS9073Application for a Health Insuring Corporation Certificate of Authority
INS9074Filing Requirements For Service Area Expansion Request
INS9100HIC Guidelines / Checklist For Evidence of Coverage Documents
Market Conduct
INS0504Third-Party Payer Response Form
INS0505Provider Complaint Form
INS0507Credentialing Contract Complaint Form
INS0508Credentialing Contract Response Form
Property & Casualty
INS4012Property and Casualty Profit & Loss Statement
INS4023Statement of Premium Taxes for Unauthorized Insurers
INS4024Surplus Lines Affidavit of Originating Agent
Adoption of Rating Bureau Prospective Loss Cost
Calculation of Company Loss Cost Multiplier
Expedited Filing Transmittal Document for Terrorism Risk Insurance Forms & Pricing
Instructions for Filing Transmittal Form
NAIC Transmittal Form
Ohio Title Agent Surety Bond
Purchasing Group Registration Form
Risk Retention Group Registration Form
Surplus Lines Yearly Treasurer's Report

The State of Ohio is an Equal Opportunity Employer

50 W. Town Street, Third Floor - Suite 300   Columbus, Ohio   43215
General Info: 614-644-2658  |  Consumer Hotline: 800-686-1526  |  Fraud Hotline: 800-686-1527  |  OSHIIP Hotline: 800-686-1578