Official Website of the Mississippi Insurance Department > Licensing > Licensing Forms and Fees

Licensing Forms and Fees

The following is a list of licensing forms and fees. Forms can be downloaded. Applications can be downloaded or completed electronically on SIRCON/Vertafore or NIPR.

Licensing Forms

  • Non Resident Adjuster Affidavit – Form
     (Updated 07/01/18)
  • Risk Purchasing Group – Form
  • Risk Retention Group – Form
  • Public Adjuster E&O Coverage Certification – Form
  • Public Adjuster Surety Bond – Form
  • Profession Bail Bond Agent Financial Report – Form
  • Limited Surety Appointment Form – Form
  • Personal Security – Irrevocable Security Power – Form
  • Viatical Settlement Provider Affidavit – Form
  • Change of Address – Form, Online (Sircon/Vertafore or NIPR)
  • Entity Change of Address – Form
  • Certificate of Authority (appointment) – $25.00 – Form
  • Duplicate License – $25.00 – Form, Online
  • Letter of Certification (Letter of Good Standing) – $20.00 – Form, Online
  • Letter of Clearance – $20.00 – Form
  • License Amendment – $25.00 – Individual Form, Online
  • License Amendment – $50.00 – Entity Form, Online

License Fees

  • Automobile Club – $5.00
  • Bail Agent, Professional – $100.00
    • Limited Surety
    • Personal Surety
  • Bail Enforcement or Soliciting Agent – $40.00
  • Burial Agent – $5.00
  • Legal Agent – $10.00
  • Insurance Producer – $100.00
    • Life, Accident & Health
    • Property
    • Casualty
    • Personal Lines
    • Variable Life and Variable Annuity Products
  • Limited Line Credit Insurance Producer – $100.00
  • Limited Lines Insurance Producer – $100.00
    • Industrial Fire
    • Industrial Life Accident and Health
    • Surety
    • Title
    • Trip Accident and Baggage
    • Car Rental
    • Crop
    • Travel
  • Managing General Agent (individual) – $100.00
  • Reinsurance Intermediary Managers/Brokers (individual) – $50.00
  • Risk Retention Agent – $50.00
  • Supervising General Agent (individual) – $100.00
  • Surplus Lines Insurance Producer – $100.00
  • Temporary Limited Lines Insurance Producer – $100.00
  • Temporary Insurance Producer – $100.00
  • Viatical Settlement Representative or Broker – $50.00
  • Individual Adjuster fees – $100.00
    • Independent Adjuster
    • Emergency
    • Trainee
    • Public Adjuster
    • Emergency Public Adjusters
    • Public Adjuster Trainee

Entity Fees

  • Independent Adjuster Entity – $400.00
  • Public Adjuster Entity – $400.00
  • Insurance Producer Entity – $200.00
  • Limited Lines Insurance Producer Entity – $200.00
  • Limited Line Credit Insurance Producer Entity – $200.00
  • Managing General Agent Entity – $100.00
  • Portable Electronics Insurance Producer Business Entity – $5,000.00
  • Reinsurance Intermediary Manager or Broker Entity – $100.00
  • Supervising General Agent Entity – $100.00
  • Third Party Administrator – $200.00
  • Transportation Network Company(TNC) – $5,000
  • Viatical Settlement Entity Representative or Broker (entity) – $50.00
  • Viatical Settlement Provider – $200.00

Online Services

The following services are available online at Sircon/Vertafore:

The following services are available online at NIPR: