DEPARTMENT OF INSURANCE

Materials Incorporated by Reference

Chapter	Regulation	Description
CHAPTER-2	806 KAR 2:088.	Verification of Risk Location Systems.	Verification Data Manual 1/2009 Application for Verification of Risk Location System or Program, 11/2008
CHAPTER-2	806 KAR 2:095	Accounting and reporting requirements for collecting local government premium tax.	FORM LGPT 142 FORM LGPT 140 FORM LGPT 141
CHAPTER-3	806 KAR 3:190	Risk-based capital for insurers.	"Risk-Based Capital Forecasting & Instructions, Life" (2011)
CHAPTER-3	806 KAR 3:210	Privacy of consumer financial and health information.	PVCY-01, "Sample Clauses and Examples", (Edition 11/01) "Model Privacy Forms & General Instructions", May 2017
CHAPTER-3	806 KAR 3:240	Corporate governance annual disclosure	"Corporate Governance Annual Disclosure", 07/19
CHAPTER-5	806 KAR 5:025	Credit for reinusrance.	"Certificate of Certified Reinsurer," Form CR-1 (09/19) "Form CR-F" (09/19) "Form CR-S" (09/19) "Certificate of Assuming Insurer," Form AR-1 December 95 Form RJ-1 9-21 NEW
CHAPTER-6	806 KAR 6:080	Reserve standards for individual health insurance policies	"Reserve Standards for Individual Health Insurance", 6/2020
CHAPTER-6	806 KAR 6:120	Recognition of preferred mortality tables for use in determining minimum reserve liabilities.	2001 CSO Mortality Table/2001 CSO Preferred Class Structure Mortality Table
CHAPTER-6	806 KAR 6:060	Reserve liabilities, cash surrender values, and nonforfeiture benefits for plans of life insurance with separate rates for smokers and nonsmokers.	"1980 CSO Table (1980)" "Ten (10) Year Select Mortality Factors (1980)" "1980 CET Table (1980)" "1958 CSO Table (1958)" "1958 CET Table (1958)"
CHAPTER-6	806 KAR 6:075	Valuation of life insurance policies.	Select Mortality Factors Male and Female Smoker and Non Smoker 1998 Edition 2001 CSO Mortality Table (2001)
CHAPTER-6	806 KAR 6:010	Valuation standards; audits.	"1958 Commissioners Standard Ordinary Table of Mortality", 1958 "2001 Commissioner Standard Ordinary Male Composite Ultimate Mortality Table", 2001
CHAPTER-6	806 KAR 6:100	Actuarial opinion and memorandum.	"Table of Reserves and Liabilities", 5/2009
CHAPTER-6	806 KAR 6:130	Minimum standards for determining reserve liabilities and nonforfeiture values for preneed insurance.	https://mort.soa.org/
CHAPTER-8	806 KAR 8:010	Valuation of assets on deposit.	Form143 6
CHAPTER-9	806 KAR 9:190	Disclosure requirements for financial institutions authorized to engage in insurance agency activities.	FI-03, "Financial Institution Disclosures", (8/2020 edition) Form FI-02 Free Choice of Agent
CHAPTER-9	806 KAR 9:030	Adjuster licensing restrictions	Form 8307 Request for Unlicensed Adjusters 5-2019
CHAPTER-9	806 KAR 9:025	Licensing Process.	Form 8301 Individual Application CLEAN 9-21 Form CE AFF 304 CLEAN 9-21 Form KYP-01 Provider Approval CLEAN 9-21 Form CE PL 100 NAIC Recommended Guidelines for CE Online Courses 8 2019 Form 8301-BE Bus Entity App CLEAN 9-21 Form 8302-AP Appointment CLEAN 9-2021 Form 8302-TE Termination CLEAN 9-2021 Form 8303 CLEAN 9-21 Form 8304-Exam Retake CLEAN 9-21 Form 8305-BE Designation 9-21 Form MLW 01 Military Request CLEAN 9-21 Form CE PL 200 NAIC CE Reciprocity Form 5-2019
CHAPTER-9	806 KAR 9:390	Portable Electronic Retailer license	Form PEI_BE Portable Elect Retailer 2022
CHAPTER-9	806 KAR 9:360	Pharmacy Benefit Manager License.	PBM License Application 2021 CLEAN
CHAPTER-9	806 KAR 9:380	Limited lines self-storage space insurance requirements	Form Self-Service Storage Space Locations 2022
CHAPTER-9	806 KAR 9:390	Portable Electronic Retailer license	Form PEI-Locations 22
CHAPTER-11	806 KAR 11:010	Industrial insured, government entity insured, and exempt commercial policyholder.	Form ECP-1 P&C Exempt Commercial Policyholder Affidavit 2000 GEI-1 P & C Government Entity Insured Affidavit Form II-1 P & C Industrial Insured Affidavit
CHAPTER-12	806 KAR 12:060	Health Insurance replacement.	APPENDIX A NOTICE TO APPLICANT REGARDING REPLACEMENT OF HEALTH INSURANCE
CHAPTER-12	806 KAR 12:140	Life insurance illustrations.	"Actuarial Standard of Practice No. 24, Compliance with the NAIC Life Insurance Illustrations Model Regulation", February 2007
CHAPTER-12	806 KAR 12:170	Life Insurance Disclosures	"Life Insurance Buyer’s Guide, "National Association of Insurance Commissioners", 2018
CHAPTER-12	806 KAR 12:080	Replacement of life insurance and annuity contracts	"Office Form A, Important Notice: Replacement of Life Insurance or Annuities", April 2005 "Office Form b, Notice Regarding Replacing Your Life Insurance Policy Or Annuity", April 2005 "Office Form C, Important Notice: Replacement of Life Insurance or Annuities", April 2005
CHAPTER-12	806 KAR 12:180	Military sales practices.	Department of Defense Instruction Number 1344.07, Personal Commercial Solicitation on DoD Installations "Department of Defense Form 2885, Personal Commercial Solicitation Evaluation"
CHAPTER-12	806 KAR 12:010	This administrative regulation clarifies the minimum standards for advertising as established in KRS 304.12-010 and 304.12-020.	FORM 440 2021
CHAPTER-12	806 KAR 12:120	Suitability in annuity transactions.	Consumer Decision to Purchase an Annuity NOT Based on a Recommendation 12-120 Insurance Agent Producer Disclosure For Annuities 12-120 Consumer Refusal to Provide Information 12-120
CHAPTER-13	806 KAR 13:130	Experience modification factors for workers' compensation insurers.	NAIC Buyers Guide Deferred Annuites 2013
CHAPTER-13	806 KAR 13:150	Property and casualty rate and rule filings.	Uniform Property & Casualty Product Coding Matrix Clean LC-1 P and C 2007 LC-2 P and C 2007 PC TD-1 Transmittal Document CLEAN
CHAPTER-14	806 KAR 14:007	Rate and form filing for health insurers.	HIPMC-R4 HIPMC-F16 HIPMC-R36 HL-F11 HIPMC-F1 2021
CHAPTER-15	806 KAR 15:050	Reporting and general requirements for settlement providers and brokers.	LS6_Settlement Provider Cert Form ls3_031209 (1) ls2_031209 (1) ls1_031209 (1) Form VOC
CHAPTER-15	806 KAR 15:090	Notice of rights as an owner of a life insurance policy.	Notice 126 2021
CHAPTER-15	806 KAR 15:050	Reporting and general requirements for settlement providers and brokers.	LS7_Form 2020 LifeSettlementGuide 2020
CHAPTER-17	806 KAR 17:081	Minimum standards for long-term care insurance policies	"Disclosures and Language for Long-term Care Policies and Certificates, HIPMC-LTC10", 09/2008
CHAPTER-17	806 KAR 17:083	Kentucky long-term care partnership insurance program.	"Important Information About Your Kentucky Long-Term Care Partnership Insurance, LTCPIP-1", 12/2008
CHAPTER-17	806 KAR 17:160	Creditable coverage for health insurance.	Form HIPMC-CC1, "Certificate of Individual Health Plan Coverage", Kentucky Department of Insurance, January 2006 edition
CHAPTER-17	806 KAR 17:350	Guaranteed Acceptance Program (GAP) reporting requirements	Guaranteed Acceptance Program Electronic Report Format - Monthly for GAP Participating Insurers, HIPMC-GAPERF-M-1 (04/01)
CHAPTER-17	806 KAR 17:270	Telehealth claim forms and records	Form HCFA - 1500, "Health Insurance Claim Form" (12-90 Edition)
CHAPTER-17	806 KAR 17:570	Minimum standards for Medicare supplement insurance policies and certificates.	"HL-MS-2", July 2009 edition "HL-MS-3", July 2009 edition "HL-MS-4", October 2009 edition "HL-MS-5", May 2018 edition "HL-MS-06", July 2009 edition "HL-MS-07", July 2009 edition "HL-MS-08", October 2009 edition "Plan Benefit Chart", April 2018
CHAPTER-17	806 KAR 17:081	Minimum standards for long-term care insurance policies	"Rescission Reporting Form for Long-term Care Policies, HIPMC-LTC-3", 09/2008
CHAPTER-17	806 KAR 17:480	Uniform evaluation and reevaluation of providers.	"Kentucky Application for Provider Evaluation and Reevaluation", Form KAPER-1 (11/2019)
CHAPTER-17	806 KAR 17:575	Pharmacy benefit managers.	"Pharmacy Benefit Manager Annual Report," June 2017
CHAPTER-17	806 KAR 17:350	Guaranteed Acceptance Program (GAP) reporting requirements	Guaranteed Acceptance Program Affidavit, HIPMC-GAPAFF-1 (06/01) Guaranteed Acceptance Program (GAP) Data Certification Form, HIPMC-GAPC-1 (12/00) Guaranteed Acceptance Program Electronic Report Format - Annual for GAP Participating Insurers, HIPMC-GAPERF-A-1 (12/00)
CHAPTER-17	806 KAR 17:360	Prompt payment of claims.	"Prompt Payment Reporting Manual, DIPRPPR1",7/2018
CHAPTER-17	806 KAR 17:570	Minimum standards for Medicare supplement insurance policies and certificates.	"HL-MS-1", July 2009 edition
CHAPTER-17	806 KAR 17:081	Minimum standards for long-term care insurance policies	"Long-term Care Insurance Personal Worksheet, HIPMC-LTC-1", 09/2008 "Long-term Care Insurance Potential Rate Increase Disclosure Form, HIPMC-LTC-2", 09/2008 "Claims Denial Reporting Form for Long-term Care Insurance, HIPMC-LTC-4", 09/01 Things You Should Know Before You Buy Long-term Care Insurance, HIPMC-LTC-5", 09/2008 "Long-term Care Insurance Suitability Letter, HIPMC-LTC-6", 09/2008 "Outline of Coverage, HIPMC-LTC-7", 09/2008 "Notice to Applicant Regarding Replacement of Individual Accident and Sickness or Long-term Care Insurance, HIPMC-LTC-8", 09/2008 "Notice to Applicant Regarding Replacement of Accident and Sickness or Long-term Care Insurance, HIPMC-LTC-9", 09/2008 "Long-term Care insurance replacement and lapse reporting form, HIPMC-LTC-11", 09/2008
CHAPTER-17	806 KAR 17:450	Insurance purchasing outlet requirements.	"Insurance Purchasing Outlet Application for Registration," HIPMC-IPO-1, (7/02) "Annual Report on Operations of Insurance Purchasing Outlet," HIPMC-IPO-2, (9/02) "Annual Financial Statement of Insurance Purchasing Outlet," HIPMC-IPO-3, (9/02)
CHAPTER-17	806 KAR 17:270	Telehealth claim forms and records	ADA Form - J588, "Dental Claim Form" (1999 version 2000)
CHAPTER-17	806 KAR 17:100	Certificate of filing for provider-sponsored networks.	Form 996 8
CHAPTER-17	806 KAR 17:085	Minimum standards for short-term nursing home insurance policies.	Outline of Coverage Template HIPMC-STN1 2021
CHAPTER-17	806 KAR 17:270	Telehealth claim forms and records.	2019ADADentalClaim Form_2019May Sample 1500_2012_02
CHAPTER-17	806 KAR 17:300	This administrative regulation establishes the filing requirements of provider agreements, subcontract agreements, and risk sharing arrangements.	HIPMC R1 NEW 10-21
CHAPTER-17	806 KAR 17:240	Data reporting requirements.	HIPMC-DR-1 9-21-21
CHAPTER-17	806 KAR 17:300	Provider agreement and risk-sharing agreement filing requirements	HIPMC R1 NEW 10-21
CHAPTER-17	806 KAR 17:290	Independent External Review Program.	HIPMC-IRE-1 Application for Certificate of an Independent Review Entity 1_1_2023-INTERACTIVE HIPMC-IRE-2 Assignment of Independent Review Entity Form1_1_2023-INTERACTIVE HIPMC-IRE-3 External Review Decision Notification Form 1_1_2023-INTERACTIVE HIPMC-IRE-4 Annual Independent Review Entity Report Form 1_1_2023-INTERACTIVE HIPMC-IRE-6 External Review Information Face Sheet 1_1_2023-INTERACTIVE
CHAPTER-17	806 KAR 17:450	Insurance purchasing outlet requirements.	Health_j_HIPMC-IPO-4Quarterly_Financial
CHAPTER-17	806 KAR 17:575	Pharmacy benefit managers.	PBMAnnualReportFinal2017 PBM External Annual Report Policy
CHAPTER-17	806 KAR 17:280	Registration, utilization review, and internal appeal.	HIPMC-STE-1 Step TherapyException Report 1-2023
CHAPTER-17	806 KAR 17:590	Annual Report on Providers Prescribing Medication for Addiction Treatment	Pharmacy Claims SDR Rx 10-21
CHAPTER-17	806 KAR 17:280	Registration, utilization review, and internal appeal.	HIPMC-UR-1 Utilization Review Registration Application 1_1_2023-INTERACTIVE HIPMC-MD-1 Medical Director Form 1_1_2023-INTERACTIVE (1)
CHAPTER-17	806 KAR 17:230	Requirements regarding medical director’s signature on health care benefit denials.	HIPMC-MD-1 2021
CHAPTER-17	806 KAR 17:280	Registration, utilization review, and internal appeal.	HIPMC-UR-2 Utilization Review Annual Report 1_1_2023-INTERACTIVE
CHAPTER-17	806 KAR 17:290	Independent External Review Program.	HIPMC-IRE-5 Approval of an External Review Fee in Excess of 800 1_1_2023
CHAPTER-17	806 KAR 17:590	Annual Report on Providers Prescribing Medication for Addiction Treatment	Medical Claims SDR 10-21
CHAPTER-17	806 KAR 17:585	Annual Report Mental Health Parity Nonquantitative Treatment Limitation Compliance	NQTL Reporting Form 5.22
CHAPTER-37	806 KAR 37:010	Insurance holding company systems.	"Form D Prior Notice of a Transaction," August 2014
CHAPTER-37	806 KAR 37:010	Insurance holding company systems.	"Form D Prior Notice of a Transaction," August 2014
CHAPTER-37	806 KAR 37:010	Insurance holding company systems.	"Form B Insurance Holding Company System Annual Registration Statement," August 2014 "Form A Statement Regarding the Acquisition of Control of or Merger With a Domestic Insurer," October 2014
CHAPTER-37	806 KAR 37:010	Insurance holding company systems.	"Form B Insurance Holding Company System Annual Registration Statement," August 2014 "Form C Summary of Changes to Registration Statement," August 2014
CHAPTER-37	806 KAR 37:010	Insurance holding company systems.	"Form C Summary of Changes to Registration Statement," August 2014
CHAPTER-37	806 KAR 37:010	Insurance holding company systems.	"Form A Statement Regarding the Acquisition of Control of or Merger With a Domestic Insurer," October 2014
CHAPTER-38	806 KAR 38:100	Risk-based capital for health organizations.	RBC Health Instructions CLEAN
CHAPTER-39	806 KAR 39:030	Kentucky No-Fault Rejection Form.	NFR KY 2022 CLEAN
CHAPTER-39	806 KAR 39:050	Self-insurance.	Application for Motor Vehicle Self-Insurance NEW
CHAPTER-40	806 KAR 40:020	Charitable health care provider registration.	806 KAR 40 020 CHPB2 2020 806 KAR 40 020 CHP2A 2020
CHAPTER-46	806 KAR 46:050	Liability self-insurance group rate, underwriting and evidence of coverage filings.	Form LSIG: EMA P & C, "E-mod Affidavit", 7/2010 Form LSIG: LC-2 P & C, "Expense Constant Supplement", 7/2010 Form LSIG: LC-1 P & C, "Calculation of Loss Cost Multiplier", 7/2010 Form LSIG: S-2 P & C, "Filing Synopsis Form", 7/2010 Form LSIG: F-1A P & C, "Face Sheet and Verification Form for Liability Self Insurance Groups", 7/2010;
CHAPTER-46	806 KAR 46:040	Forms for application and financial statements.	"Form 995 - Application for Certificate of Filing As a Liability Self-Insurance Group", 7/2020
CHAPTER-46	806 KAR 46:050	Liability self-insurance group rate, underwriting and evidence of coverage filings.	Form LSIG: S-1 P & C, "Filing Synopsis for Rates and or Rules", 7/2010
CHAPTER-46	806 KAR 46:040	Forms for application and financial statements.	"Liability Self-Insurance Group Quarterly Statement (Blank)", 7/2020 "Liability Self-Insurance Group Annual Statement (Blank)", 7/2020. "Form 101 - Trustee Confirmation of Receipt", 7/2020
CHAPTER-46	806 KAR 46:050	Liability self-insurance group rate, underwriting and evidence of coverage filings.	Form LSIG: F-2 P & C, "Forms Index", 7/2010
CHAPTER-47	806 KAR 47:010	Fraud prevention.	Uniform Suspected Insurance Fraud Reporting Form - 03-2019 - Clean
CHAPTER-49	806 KAR 49:020	Captive insurer application requirements.	Coverage, Limits and Reinsurance CI-105 (4/2001) Captive Application for Admission CI-103 (6/2020) Biographical Affidavit CI-501 (4/2001) Irrevocable Letter of Credit CI-130 (6/2020) Application for Authorization to Certify Loss Reserves and Loss Expense Reserves for Captives CI-110 (6/2020) Application for Authorization as an Independent Certified Public Accountant for Captive Insurance Business CI-120 (6/2020)
CHAPTER-52	806 KAR 52:010	Forms for application, security deposits and financial statements.	"Form 147 - Deposit Calculation for Workers’ Compensation Self-Insured Groups 6/2020 "Form 100 - Initial Application for Certificate of Filing As a Workers’ Compensation SelfInsured Group 7/2020 "Form 102 - Trustee Confirmation of Receipt 7/2020 "Workers’ Compensation Self-Insured Group Quarterly Statement (Blank) 7/2020 "Form 826 - Safekeeping Agreement for Workers’ Compensation Self-Insured Groups 7/2020 "Form 145 - Transaction Sheet for Securities Held Under Safekeeping with Designated Custodian Banks 7/2020 "Form 142 - Letter of Credit 7/2020
CHAPTER-52	806 KAR 52:030	Workers’ compensation self-insured group rate, rule and form filings.	WC SIG EMA PC WC SIG F-1A PC WC SIG F-2 PC WC SIG LC-1 PC WC SIG S-1 PC WC SIG S-2 PC WC SIG LC-2 PC
CHAPTER-52	806 KAR 52:010	Forms for application, security deposits and financial statements.	"Workers’ Compensation Self-Insured Group Annual Statement (Blank) 7/2020 "Form 141 - Election Form for Designation of Custodian Bank for Safekeeping of Securities 7/2020