69O-136.100, F.A.C.
69O-136.100. Forms Incorporated by Reference
Cite as Fla. Admin. Code r. 69O-136.100
(1) The forms incorporated in this rule are available and may be printed from the Office of Insurance Regulation’s website: floir.gov/iportal, and are hereby incorporated by reference.
(2)(a) Forms OIR-A3
1. Form OIR-A3-110, “License Continuance Form Service Warranty Association,” effective 01/25, hereby incorporated by reference and available at https://www.flrules.org/Gateway/reference.asp?No=Ref-17411;
2. Form OIR-A3-453, “Premium Finance Company Surety Bond,” effective 01/25, hereby incorporated by reference and available at https://www.flrules.org/Gateway/reference.asp?No=Ref-17413;
3. Form OIR-A3-455, “Home or Service Warranty Association Surety Bond,” effective 01/25, hereby incorporated by reference and available at https://www.flrules.org/Gateway/reference.asp?No=Ref-17414;
4. Form OIR-A3-467 LR, “Application for License Continuance Motor Vehicle Service Agreement Company,” effective 01/25, hereby incorporated by reference and available at https://www.flrules.org/Gateway/reference.asp?No=Ref-17415;
5. Form OIR-A3-478, “Legal Expense Insurance Corporation Surety Bond,” effective 01/25, available at https://www.flrules.org/Gateway/reference.asp?No=Ref-17416;
6. Form OIR-A3-955, “License Continuance Form Service Warranty Association Manufacturer or Affiliate,” effective 01/25, hereby incorporated by reference and available at https://www.flrules.org/Gateway/reference.asp?No=Ref-17417;
7. Form OIR-A3-1073, “Application for Renewal of License Home Warranty Association,” effective 01/25, hereby incorporated by reference and available at https://www.flrules.org/Gateway/reference.asp?No=Ref-17418;
8. Form OIR-A3-1077, “Application for License Continuance Legal Expense Insurance,” effective 01/25, hereby incorporated by reference and available at https://www.flrules.org/Gateway/reference.asp?No=Ref-17419; and
9. Form OIR-A3-1563, “Application for Renewal of License Premium Finance Company,” effective 01/25, hereby incorporated by reference and available at https://www.flrules.org/Gateway/reference.asp?No=Ref-17420.
(b) Form OIR-B1-PCR3, “Filing requirements Advisory Organization,” effective 7/23, hereby incorporated by reference and available at http://www.flrules.org/Gateway/reference.asp?No=Ref-16192, electronically at floir.gov/iportal.
(c) Form OIR-B2-1093, “Small Employer Carrier’s Application to Become a Risk Assuming Carrier or a Reinsuring Carrier, as Required by section 627.6699(9), Florida Statutes,” effective 7/23, available at http://www.flrules.org/Gateway/reference.asp?No=Ref-16193.
(d) Forms OIR-C1
1. Form OIR-C1-0508, “Uniform Certificate of Authority Application (UCAA) Affidavit of Lost Certificate of Authority,” effective 7/23, available at http://www.flrules.org/Gateway/reference.asp?No=Ref-16202;
2. Form OIR-C1-0510, “Uniform Certificate of Authority Application (UCAA) Corporate Amendments Application Application to Amend Certificate of Authority,” effective 7/23, available at http://www.flrules.org/Gateway/reference.asp?No=Ref-16206;
3. Form OIR-C1-0511, “Uniform Certificate of Authority Application (UCAA) Corporate Amendments Application Checklist for Corporate Amendments Application Only,” effective 7/23, available at http://www.flrules.org/Gateway/reference.asp?No=Ref-16208;
4. Form OIR-C1-0512, “Uniform Certificate of Authority Application Questionnaire for Adding or Deleting Lines of Business to an Existing Certificate of Authority,” effective 7/23, available at http://www.flrules.org/Gateway/reference.asp?No=Ref-16210;
5. Form OIR-C1-0522, “Uniform Certificate of Application (UCAA) Change of Mailing Address/Contact Notification Form,” effective 7/23, http://www.flrules.org/Gateway/reference.asp?No=Ref-16214;
6. Form OIR-C1-100, “Application for Permit Domestic Stock or Mutual Insurer”, effective 08/26, available at https://flrules.org/Gateway/reference.asp?No=Ref-19695.
7. Form OIR-C1-101, “Application to Redomesticate a Stock or Mutual Insurer”, effective 08/26, available at https://flrules.org/Gateway/reference.asp?No=Ref-19697.
8. Form OIR-C1-144, “Service of Process Consent & Agreement,” effective 08/26, available at http://flrules.org/Gateway/reference.asp?No=Ref-19680;
9. Form OIR-C1-150, “Application for Acquisition of the Attorney-in-Fact of a Domestic Reciprocal Insurer,” effective 01/25, https://www.flrules.org/Gateway/reference.asp?No=Ref-17424;
10. Form OIR-C1-151, “Application for Certificate of Authority Domestic Reciprocal Insurer,” effective 01/25, available at https://www.flrules.org/Gateway/reference.asp?No=Ref-17425;
11. Form OIR-C1-152, “Letter of Notification Acquisition of the Attorney-in-Fact of a Domestic Reciprocal Insurer,” effective 01/25, available at https://www.flrules.org/Gateway/reference.asp?No=Ref-17426;
12. Form OIR-C1-153, “Application for Merger or Conversion Reciprocal Insurer,” effective 01/25, hereby incorporated by reference and available at https://www.flrules.org/Gateway/reference.asp?No=Ref-17427;
13. Form OIR-C1-448, “Application for Acquisition of Controlling Stock, Ownership Interest, Assets, or Control of a Florida Specialty Insurer; Merger or Consolidation,” effective 08/26, available at http://flrules.org/Gateway/reference.asp?No=Ref-19681;
14. Form OIR-C1-454, “Personal Financial Statement,” effective 01/25, hereby incorporated by reference and available at https://www.flrules.org/Gateway/reference.asp?No=Ref-17430;
15. Form OIR-C1-471, “Application for Provisional Certificate of Authority for a Continuing Care Provider,” effective 01/25, hereby incorporated by reference and available at https://www.flrules.org/Gateway/reference.asp?No=Ref-17431;
16. Form OIR-C1-473, “Application for Certificate of Authority for a Continuing Care Provider,” effective 01/25, hereby incorporated by reference and available at https://www.flrules.org/Gateway/reference.asp?No=Ref-17432;
17. Form OIR-C1-480, “Application for Certificate of Authority Legal Expense Insurance,” effective 01/25, available at https://www.flrules.org/Gateway/reference.asp?No=Ref-17433;
18. Form OIR-C1-483, “Application for Certificate of Authority Prepaid Health Clinic,” effective 01/25, hereby incorporated by reference and available at https://www.flrules.org/Gateway/reference.asp?No=Ref-17434;
19. Form OIR-C1-490, “Application for License Home Warranty Association,” effective 01/25, hereby incorporated by reference and available at https://flrules.org/Gateway/reference.asp?No=Ref-17911;
20. Form OIR-C1-513, “Application for Registration as a Risk Retention Group,” effective 08/26, available at http://flrules.org/Gateway/reference.asp?No=Ref-19682;
21. Form OIR-C1-515, “Application for Registration as a Risk Purchasing Group,” effective 01/25, available at http://www.flrules.org/Gateway/reference.asp?No=Ref-17912;
22. Form OIR-C1-523, “Protected Cell Captive Insurance Company Add Protected Cell,” effective 08/26, available at https://flrules.org/Gateway/reference.asp?No=Ref-19696.
23. Form OIR-C1-845, “Application for Certificate of Authority Commercial Self-Insurance Fund,” effective 01/25, available at http://www.flrules.org/Gateway/reference.asp?No=Ref-17913;
24. Form OIR-C1-908, “Application for Permit Domestic Reciprocal Insurer,” effective 01/25, available at http://www.flrules.org/Gateway/reference.asp?No=Ref-17914;
25. Form OIR-C1-916, “Application for Eligibility as a Surplus Lines Insurer,” effective 08/26, available at www. http://flrules.org/Gateway/reference.asp?No=Ref-19683;
26. Form OIR-C1-918, “Application for Acquisition of Controlling Stock of a Florida Domestic Insurer,” effective 01/25, available at https://www.flrules.org/Gateway/reference.asp?No=Ref-17442;
27. Form OIR-C1-942, “Application for Certificate of Authority Health Maintenance Organization,” effective 08/26, hereby incorporated by reference and available at https://flrules.org/Gateway/reference.asp?No=Ref-19684;
28. Form OIR-C1-957, “Instructions for Statutory Compliance of Forms: Premium Finance Companies,” effective 01/25, hereby incorporated by reference and available at https://www.flrules.org/Gateway/reference.asp?No=Ref-17915;
29. Form OIR-C1-958, “Application for License Premium Finance Company,” effective 01/25, hereby incorporated by reference and available at https://www.flrules.org/Gateway/reference.asp?No=Ref-17445;
30. Form OIR-C1-983, “Application for Certificate of Authority Multiple Employer Welfare Arrangement,” effective 01/25, hereby incorporated by reference and available at https://www.flrules.org/Gateway/reference.asp?No=Ref-17446;
31. Form OIR-C1-989, “Application for License Service Warranty Association Manufacturer or Affiliate,” effective 01/25, hereby incorporated by reference and available at https://www.flrules.org/Gateway/reference.asp?No=Ref-17447;
32. Form OIR-C1-994, “Application for License Motor Vehicle Service Agreement Company,” effective 01/25, hereby incorporated by reference and available at https://www.flrules.org/Gateway/reference.asp?No=Ref-17448;
33. Form OIR-C1-997, “Application for License Service Warranty Association,” effective 01/25, hereby incorporated by reference and available at https://www.flrules.org/Gateway/reference.asp?No=Ref-17449;
34. Form OIR-C1-1000, “Application for Permit Captive Insurer,” effective 08/26 available at https://flrules.org/Gateway/reference.asp?No=Ref-19685;
35. Form OIR-C1-1001, “Application to Redomesticate a Captive Insurer,” effective 08/26 available at https://flrules.org/Gateway/reference.asp?No=Ref-19686;
36. Form OIR-C1-1075, “Application for Certificate of Authority of an Insurance Administrator,” effective 08/26, hereby incorporated by reference and available at https://flrules.org/Gateway/reference.asp?No=Ref-19687;
37. Form OIR-C1-1119, “Application for Certificate of Authority Prepaid Limited Health Service Organization,” effective 01/25, hereby incorporated by reference and available at https://www.flrules.org/Gateway/reference.asp?No=Ref-17451;
38. Form OIR-C1-1208, “Notification to the Office of Insurance Regulation as a Qualifying Issuer of Donor Annuity Agreements Pursuant to section 627.481, F.S.,” effective 01/25, is hereby incorporated by reference and available at https://www.flrules.org/Gateway/reference.asp?No=Ref-17452.
39. Form OIR-C1-1227, “Application for License Viatical Settlement Provider,” effective 08/26, hereby incorporated by reference and available at https://flrules.org/Gateway/reference.asp?No=Ref-19688;
40. Form OIR-C1-1294, “Notice of Intent to Use a Related Provider Trust,” effective 08/26, hereby incorporated by reference and available at https://flrules.org/Gateway/reference.asp?No=Ref-19689;
41. Form OIR-C1-1413, “Uniform Certificate of Authority Application (UCAA) Expansion Application,” effective 7/23, available at http://www.flrules.org/Gateway/reference.asp?No=Ref-16230;
42. Form OIR-C1-1414, “Uniform Certificate of Authority Application (UCAA) Expansion Application Checklist For Expansion Application Only,” effective 7/23, available at http://www.flrules.org/Gateway/reference.asp?No=Ref-16231;
43. Form OIR-C1-1416, “Uniform Certificate of Authority Application (UCAA) Lines of Insurance,” effective 07/23, available at http://www.flrules.org/Gateway/reference.asp?No=Ref-16232;
44. Form OIR-C1-1422, “Uniform Certificate of Authority Application Questionnaire,” effective 7/23, available at http://www.flrules.org/Gateway/reference.asp?No=Ref-16233;
45. Form OIR-C1-1424, “Uniform Certificate of Authority Application,” effective 7/23, available at http://www.flrules.org/Gateway/reference.asp?No=Ref-16234;
46. Form OIR-C1-1467, “Disclaimer of Control - Individual,” effective 7/21, available at http://www.flrules.org/Gateway/reference.asp?No=Ref-14442
47. Form OIR-C1-1468, “Disclaimer of Control - Entity,” effective 7/21, available at https://www.flrules.org/Gateway/reference.asp?No=Ref-14443;
48. Form OIR-C1-1522, “Primary Application Florida Specific Information,” effective 7/23, available at http://www.flrules.org/Gateway/reference.asp?No=Ref-16235;
49 Form OIR-C1-1524, “Uniform Certificate of Authority Application (UCAA) Uniform Consent to Service of Process,” effective 12/19, available at https://www.flrules.org/Gateway/reference.asp?No=Ref-14444;
50. Form OIR-C1-1606, “Application for License Discount Plan Organization (DPO),” effective 01/25, hereby incorporated by reference and available at https://www.flrules.org/Gateway/reference.asp?No=Ref-17453;
51. Form OIR-C1-1654, “Determination of Eligibility to Operate as an Alien Insurer in Florida Pursuant to Section 624.402(9), Florida Statutes,” effective 7/23, available at http://www.flrules.org/Gateway/reference.asp?No=Ref-16236;
52. Form OIR-C1-1663, “Application for Registration Life Expectancy Provider,” effective 08/26, hereby incorporated by reference and available at https://flrules.org/Gateway/reference.asp?No=Ref-19690;
53. Form OIR-C1-2069, “Letter of Notification,” effective 01/25, available at http://www.flrules.org/Gateway/reference.asp?No=Ref-17454;
54. Form OIR-C1-2176, “Letter of Notification/Registration to Operate as a Non-US Based (Alien) Insurer (also referred to as “Offshore Insurer”) in Florida Pursuant to Section 624.402(8), Florida Statutes,” effective 7/23, available at http://www.flrules.org/Gateway/reference.asp?No=Ref-16238;
55. Form OIR-C1-2211, “Disclaimer of Control – Investment Companies,” effective 7/21, available at https://www.flrules.org/Gateway/reference.asp?No=Ref-14445;
56. Form OIR-C1-2218, “Application for Expansion of a Certificated Continuing Care Facility,” effective 01/25, hereby incorporated by reference and available at https://www.flrules.org/Gateway/reference.asp?No=Ref-17455;
57. Form OIR-C1-2219, “Application for the Simultaneous Acquisition of a Continuing Care Facility and Issuance of a Certificate of Authority to a Provider,” effective 01/25, hereby incorporated by reference and available at https://www.flrules.org/Gateway/reference.asp?No=Ref-17916;
58. Form OIR-C1-2220, “Consolidated Application for Provisional Certificate of Authority and Certificate of Authority for a Continuing Care Provider,” effective 01/25, hereby incorporated by reference and available at https://www.flrules.org/Gateway/reference.asp?No=Ref-17457;
59. Form OIR-C1-2221, “Management Information Form,” effective 08/26, available at https://flrules.org/Gateway/reference.asp?No=Ref-19691;
60. Form OIR-C1-PCR1, “Application for License Rating Organization,” effective 08/26, hereby incorporated by reference and available at http://flrules.org/Gateway/reference.asp?No=Ref-19692; and
61. Form OIR-C1-PCR2, “License Renewal Rating Organization,” effective 01/25, hereby incorporated by reference and available at http://www.flrules.org/Gateway/reference.asp?No=Ref-17459, filed electronically at floir.com/iportal.
(e) Forms OIR-D0
1. Form OIR-D0-896, “UCAA Proforma Financial Statements, Property and Casualty Insurance Company,” effective 1/19, available at https://www.flrules.org/Gateway/reference.asp?No=Ref-14448;
2. Form OIR-D0-904, “UCAA Proforma Financial Statements, Life & Health Insurer,” effective 1/19, available at https://www.flrules.org/Gateway/reference.asp?No=Ref-16761;
3. Form OIR-D0-2119, “UCAA Proforma Financial Statements, Title Insurance Company,” effective 1/19, available at https://www.flrules.org/Gateway/reference.asp?No=Ref-14593; and
4. Form OIR-D0-2165, “UCAA Proforma Financial Statements, Health,” effective 1/19, available at https://www.flrules.org/Gateway/reference.asp?No=Ref-14450.
(3) The “biographical information package” is defined as all of the forms listed in this subsection.
(a) All individuals submitting a biographical information package shall complete and submit forms:
1. Form OIR-C1-938, “Fingerprints and Social Security Number,” effective 01/25, hereby incorporated by reference and available at https://www.flrules.org/Gateway/reference.asp?No=Ref-17461; and
2. Form OIR-C1-1423, “Uniform Certificate of Authority Application (UCAA) Biographical Affidavit,” effective 12/20, hereby incorporated by reference and available at https://www.flrules.org/Gateway/reference.asp?No=Ref-14441;
(b) In addition, the individual shall submit all of the following forms that are applicable to their circumstances:
1. Form OIR-C1-0500, “UCAA Biographical Affidavit Addendum Blank,” effective 7/23, available at http://www.flrules.org/Gateway/reference.asp?No=Ref-16194;
2. Form OIR-C1-0501, “UCAA Biographical Affidavit Addendum Education,” effective 7/23, available at http://www.flrules.org/Gateway/reference.asp?No=Ref-16195;
3. Form OIR-C1-0502, “UCAA Biographical Affidavit Addendum Employment,” effective 7/23, available at http://www.flrules.org/Gateway/reference.asp?No=Ref-16196;
4. Form OIR-C1-0503, “UCAA Biographical Affidavit Addendum General,” effective 7/23, available at http://www.flrules.org/Gateway/reference.asp?No=Ref-16197;
5. Form OIR-C1-0504, “UCAA Biographical Affidavit Addendum Licenses,” effective 7/23, available at http://www.flrules.org/Gateway/reference.asp?No=Ref-16198;
6. Form OIR-C1-0505, “UCAA Biographical Affidavit Addendum Professional,” effective 7/23, available at http://www.flrules.org/Gateway/reference.asp?No=Ref-16199;
7. Form OIR-C1-0506, “UCAA Biographical Affidavit Addendum Residence,” effective 7/23, available at http://www.flrules.org/Gateway/reference.asp?No=Ref-16200;
8. Form OIR-C1-0507, “UCAA Biographical Affidavit Addendum Societies,” effective 7/23, available at http://www.flrules.org/Gateway/reference.asp?No=Ref-16201; and,
9. Form OIR-C1-0509, “Uniform Certificate of Authority Application (UCAA) Biographical Affidavit Cover Letter Holding Company Structure,” effective 7/23, available at http://www.flrules.org/Gateway/reference.asp?No=Ref-16203.