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Application Forms for Public Use - Not Yet Available on the Department’s Website

Application Forms - Available on the Web site | Applications and Licensing page

  1. Board of Directors Resolution and Appointment Forms Designating Superintendent of Financial Services as agent for service of process on the insurer in New York
  2. Producer Application for Reinsurance Intermediary’s License under Section 2106 of the Insurance Law – Individual Form, Original/Relicensing
  3. Producer Application for Reinsurance Intermediary’s License under Section 2106 of the Insurance Law – Entity Form, Original/Relicensing
  4. Certification by Ceding Insurer Pursuant to Insurance Regulation No. 20 – Satisfaction of regulatory requirements for taking credit for reinsurance ceded to unlicensed insurers
  5. Custodial Agreements – Proof of satisfaction of deposit requirements. Agreements must be executed by insurer and holder of custodial account and filed with Superintendent pursuant to Insurance Law Section 1314
  6. Entity Form for a License as Bail Bond Agent under Section 6802 of the Insurance Law – Corporation Form, Original/Relicensing
  7. Parental Letter of Credit Certification by Ceding Insurer Pursuant to Insurance Regulation No. 20 – Satisfaction of regulatory requirements for taking credit for reinsurance ceded to unlicensed insurers
  8. Service Contract Provider’s Bond – Proof of satisfaction of Surety bond requirement under Insurance Law Section 7903
  9. Service Contract Provider’s Custodial Agreement – Proof of satisfaction of deposit requirements under Insurance Law Section 7903
  10. Subscriber Rate Adjustment Application under 11 NYCRR 52, Group Model Health Maintenance Organization
  11. Subscriber Rate Adjustment Application under 11 NYCRR 52, Independent Practice Association Health Maintenance Organization
  12. Rate Application under Section 1120 of the Insurance Law, Child Health Plus “B” Program

Revised 11/06/2015

 

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