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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

Estimated Posting Date: April 1, 2012

(Listed from highest to lowest priority)

  1. Board of Directors Resolution and Appointment Forms Designating Superintendent of Insurance 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. Application for a License as Bail Bond Agent under Section 6802 of the Insurance Law – Corporation Form, Original/Relicensing
  7. Application for a License as Bail Bond Agent under Section 6802 of the Insurance Law – Partnership Form, Original/Relicensing
  8. Application for a License as Bail Bond Agent under Section 6802 of the Insurance Law – Limited Liability Company Form, Original/Relicensing
  9. 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
  10. Service Contract Provider’s Bond – Proof of satisfaction of Surety bond requirement under Insurance Law Section 7903
  11. Service Contract Provider’s Custodial Agreement – Proof of satisfaction of deposit requirements under Insurance Law Section 7903
  12. Regulation 87 Governmental Insurance Disclosure Statement for Use On and After December 31, 1979
  13. Producer Application for Limited Lines Rental Agent’s License under Section 2131 of the Insurance Law - Limited Liability Company, Original/Relicensing
  14. Subscriber Rate Adjustment Application under 11 NYCRR 52, Group Model Health Maintenance Organization
  15. Subscriber Rate Adjustment Application under 11 NYCRR 52, Independent Practice Association Health Maintenance Organization
  16. Rate Application under Section 1120 of the Insurance Law, Child Health Plus “B” Program
  17. Application for Limited Lines Rental Agent’s License under Section 2131 of the Insurance Law – Individual Form, Original/Relicensing
  18. Application for Limited Lines Rental Agent’s License under Section 2131 of the Insurance Law – Partnership Form, Original/Relicensing

Revised 12/08/2011