Company Licensing Forms
The Insurance Company Licensing and Registration Information Page provides access to the following forms:
- Auto Club Company Licensing
- Burial Agent Appointment Form
- Cancellation Form
- Company Authorized Signature Form
- Company License Amendments
- Fraternal Agent Appointment Form
- Life Type Producer Appointment Form
- NAIC Uniform Certificate of Authority Application
- Professional Bail Agent: Limited Surety Appointment Form
- Property and Casualty Type Appointment Form
- Surplus Lines Eligibility Application
- Surplus Lines Name/Address Change
- Title Agent Appointment Form
- UCAA Corporate Amendments
Life, Accident, and Health Forms
The Life, Accident and Health Form and Rate Filing Information Page provides access to the following forms:
- General Information
- NAIC Universal Transmittal Form
- NAIC Product Coding Matrix
- Current Requirements – Item Descriptions and related attachments
- MS State Specific Information – for completing Transmittal Document
- MS Filing Fee Form
- MSRATE – rate filing instructions
- RII 7/02 – rate increase information form
- Current Submission Requirements For
- Accident and Health
- Long Tem Care
- Medicare Supplement
- Credit Life, Credit Accident & Health
- Industrial Life, Industrial Accident & Health
- Life
Property and Casualty Forms
The Property and Casualty Rate Filing Information Page provides access to the following forms:
- Loss Cost Filing Procedures (October 19, 1990)
- Mississippi Insurer Rate Filing
- Adoption of Rate Service Organization
- Prospective Loss Costs
- MDOI Property/Casualty Rate Filing Exhibits
- Exhibit A - Statewide Average Rate Level Information
- Exhibit B - Historical Experience
- Exhibit C - Expense Information
- Exhibit D - Derivation of Target Underwriting Profit Provision
- MDOI Property/Casualty Rate Filing - General Submission Instructions
- Mississippi Expense Constant Supplement
- Mississippi Ratemaking Worksheet
- Mississippi Property and Casualty Filing Fee Form
- NAIC Product Coding Matrix
- NAIC Universal Transmittal Forms
- New Required form for all P&C Rate or Rule filings (January 8, 2007)
- Reference Filing Adoption Form
- Speed to Market Checklist
- Summary of Supporting Information Form / Calculation of Company Loss Cost Multiplier
Risk Retention and Risk Purchasing Group Checklists
The Risk Retention and Risk Purchasing Group Information provides access to the following forms:
- Purchasing Group Registration Checklist
- Risk Retention Group Registration Checklist
Statement Filing Requirements
The Statement Filing Requirements Page provides access to the following forms:
- Accredited Reinsurer Annual Statement Filing Requirements (pdf)
- Alien Surplus Lines Companies Annual Filing Requirements (pdf)
- Automobile Club Annual Statement Filing Requirements (pdf)
- Burial Associations Annual Statement Filing Requirements (pdf)
- Foreign Surplus Lines Companies Annual Statement Filing Requirements (pdf)
- Fraternal Societies Annual Statement Filing Requirements (pdf)
- Health Insurers Annual Statement Filing Requirements (pdf)
- Health Maintenance Organization Annual Statement Filing Requirements (pdf)
- Life Health and Accident Companies Annual Statement Filing Requirements (pdf)
- Property Casualty Companies Annual Statement Filing Requirements (pdf)
- Risk Retention Groups Annual Statement Filing Requirements (pdf)
- Third Party Administrator Annual Statement Filing Requirements (pdf)
- Title Companies Annual Statement Filing Requirements (pdf)
- Trusteed Reinsurer Annual Statement Filing Requirements (pdf)
Tax Filing Forms
The Tax Filing Forms Page provides access to the following forms:
- Annual Risk Purchasing Group / Risk Retention Group Premium Filing Form
- Independently Procured Insurance Form (Surplus Lines Company)
- Purchasing Group Reporting Form
- Risk Retention Group Reporting Form
- Self Procured Insurance Form (Licensed Company)
Building Plan Review Request
The Building Plan Review Request Page provides access to the following forms:
- Building Plan Review Request Application
Factory-Built Homes/Modular Homes Forms
The Factory-Built Homes/Modular Homes Page provides access to the following forms:
- Contractor Agreement
- Frequently Asked Questions
- Installation Decals Order Form
- Installer's Affidavit
- MH-1 Consumer Complaint Form
- Monthly Production Report Modular Building Units or Components Form
- Property Locator Inspection Form
- Regulation ME-2007-3: Rules and Regulations for the Uniform Standards Code for the Factory-Built
Homes Law as Related to Modular Homes
- Regulation MH-5: Rules and Regulations, Uniform Standards Code for the Factory-Built Homes Law
- Request for Data Plates Modular Housing Building Unit
- Modular Building Plan Review Request
- Sales and Set-up Educational Seminar Schedule and Registration
- Truck Decals Order Form
- Application for License for Modular Home Contractor
- Application for License for Retailers of Factory-Built Manufactured Movable Homes
- Application for License for Independent Contractor Installer/Transporter of Factory-Built Manufactured Movable Homes
- Application for License for Temporary Independent Contractor Installer/Transporter of Factory-Built Manufactured Movable Homes
- Application for License for Promotional Event Retailer of Factory-Built Manufactured Movable Homes
- Application for License for Developer of Factory-Built Manufactured Movable Homes
- Application for License for Manufacturers of Hud Factory-Built Manufactured Movable Homes
- Application for License for Manufacturers of Factory-Built Re-locatable (Modular) Homes
- Application for License for Developers of Factory-Built Re-locatable (Modular) Homes
Fire Code Enforcement Forms
The Fire Code Enforcement Page provides access to the following forms:
- Building Plan Review Request
- Rules and Regulations for the Mississippi Fire Prevention Code
Fire Investigations Forms
The Fire Investigations Page provides access to the following forms:
- Fire Damage Registry Form for Insurance Companies
- Fire Information Request Form
Fire Safety Education Forms
The Fire Safety Education Page provides access to the following forms:
- Burn Injury Report
- Civilian Fire Casualty Report
Fire Services Development Forms
The Fire Services Development Page provides access to the following forms:
- U.S. Fire Administration - Firefighter Investment Response Enhancement Grants Program
Liquefied Compressed Gas Forms
The Liquefied Compressed Gas Page provides access to the following forms:
- Funding Request Policies and Procedures
- Funding Request Form
- Mississippi Liquefied Compressed Gas Board Application for Permit, Class 1-10
- Liquefied Compressed Gas Installation Report
- Liquefied Compressed Gas Leak Check Form
- Guidelines and Procedures
- Mississippi Code Ann. § 75-57-1 through 75-57-119
- Mississippi Rules and Regulations for Liquified Compressed Gasses
- Bulletin 2010-4: Liquefied Compressed Gas Leak Checks
- Regulation 2011-2: Handling of Liquefied Compressed Gas Containers
Modular Building Plan Review Request
The Modular Building Plan Review Request Page provides access to the following forms:
- Request for Modular Housing Plan Review
Pyrotechnics Forms
The Pyrotechnics Page provides access to the following forms:
- Public Fireworks Display Permit Application
Residential Electronic Protection Systems Forms
The Residential Electronic Protection Systems Page provides access to the following forms:
- Rules and Regulations
- Licensing Application
- Notification Form
- Investigation Request Form
Producer Licensing Forms
The Producer Licensing Page provides access to the following forms:
Individual Licensing Forms
- Insurance Producer
- Life
- Accident and Health
- Property
- Casualty
- Personal Lines
- Variable Life and Variable Annuity Products
- Limited Lines Insurance Producer
- Industrial Fire
- Industrial, Life, Accident, and Health
- Surety
- Title
- Trip, Accident, and Baggage
- Car Rental
- Crop
- Travel
- Limited Line Credit Insurance Producer
- Surplus Lines Insurance Producer
- Temporary Insurance Producer
- Temporary Limited Lines Insurance Producer
Entity Licensing Forms
- Insurance Producer Entity
- Limited Lines Insurance Producer Entity
- Limited Line Credit Insurance Producer Entity
Letters of Certification/Change of Address
- Duplicate License/Change of Address/Letter of Certification or Clearance Form
- Online Forms
Adjuster Licensing Forms
The Adjuster Licensing Page provides access to the following forms:
Individual Licensing Forms
- Independent Adjuster
- Emergency
- Trainee
- Public Adjuster
- Emergency Public Adjusters
- Public Adjuster Trainee
- Public Adjuster Surety Bond
- Public Adjuster E&O Coverage Certification
Entity Licensing Forms
- Independent Adjuster Entity
- Public Adjuster Entity
Letters of Certification/Change of Address
- Duplicate License/Change of Address/Letter of Certification or Clearance Form
Additional Individual License Types Forms
The Additional Individual License Types Page provides access to the following forms:
Individual Licensing Forms
- Automobile Club
- Bail Agent, Professional
- Fingerprinting Instructions for All Bail Agent License Types
- Bail Enforcement or Soliciting Agent
- Personal Surety
- Limited/Personal Surety
- Limited Surety
- Burial Agents
- Legal
- Managing General Agent
- Reinsurance Intermediary Managers/Brokers
- Risk Retention Agent
- Supervising General Agent
- Viatical Settlement Representative or Broker
Additional Entity License Types Forms
The Additional Entity License Types Page provides access to the following forms:
Entity Licensing Forms
- Managing General Agent
- Supervising General Agent
- Third Party Administrator
- Reinsurance Intermediary Manager
- Viatical Settlement Provider
- Viatical Settlement Entity Representative or Broker
- NAIC Business Entity Form
- NAIC Uniform Service of Process Form
Prelicensing and Continuing Education Forms
The Prelicensing and Continuing Education Page provides access to the following forms:
- New Pre-Licensing and Continuing Education Guidelines and Provider Packet: effective November 1, 2009
- CE Calculation Chart: How Many Months is Your License in Effect (all licenses renewed or reinstated prior to Dec. 31, 2009)
- CE Calculation Chart: How Many Months is Your License in Effect (all licenses issued, reinstated or renewed after Jan. 1, 2010)
- NAIC Uniform Continuing Education Reciprocity Form
- How To Find Approved Prelicensing Or Continuing Education Provider/Course
Pre-Licensing Education Providers
- Guidelines
- Mississippi Education Information
Types of Examinations
- Examination Content Outlines (Study Guides)
Pre-Licensing Forms
- Prelicensing Education Course Approval Form
Continuing Education
- Insurance Producer Training Requirement for the National Flood Insurance Program Agent Leads Referral Program
Information for Continuing Education Providers
- Continuing Education Guidelines and Continuing Education Provider Packet
- Continuing Education Reciprocity Agreement
- Continuing Education Reciprocity Form (CE Course Application)
Information for Continuing Education Providers
- Pre-Licensing Education Information
Licensing Appointments Forms
The Licensing Appointments Page provides access to the following forms:
Appointment Forms
- Certificate of Authority/Appointment Form
- Professional Bail Agent: Limited Surety Appointment Form
Termination Forms
Company Authorization of Individuals to Appoint/Terminate Forms
- Company Authorized Signature Form
Health Care Forms
The Health Care Forms Page provides access to the following forms:
- Application for External Review - Use this form to request an external review for an adverse determination of a claim.
