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Materials Incorporated by Reference

ChapterRegulationDescriptionDocument Name
CHAPTER-2806 KAR 2:095Accounting and reporting requirements for collecting local government premium tax.FORM LGPT 140
FORM LGPT 142
CHAPTER-2806 KAR 2:088. Verification of Risk Location Systems.Application for Verification of Risk Location System or Program, 11/2008
CHAPTER-2806 KAR 2:095Accounting and reporting requirements for collecting local government premium tax.FORM LGPT 141
CHAPTER-2806 KAR 2:088. Verification of Risk Location Systems.Verification Data Manual 1/2009
CHAPTER-3806 KAR 3:190Risk-based capital for insurers."Risk-Based Capital Forecasting & Instructions, Life" (2011)
CHAPTER-3806 KAR 3:240Corporate governance annual disclosure"Corporate Governance Annual Disclosure", 07/19
CHAPTER-3806 KAR 3:210Privacy of consumer financial and health information."Model Privacy Forms & General Instructions", May 2017
PVCY-01, "Sample Clauses and Examples", (Edition 11/01)
CHAPTER-3806 KAR 3:170Annual audited financial reports."Financial Condition Examiner’s Handbook", 2020, National Association of Insurance Commissioners
CHAPTER-5806 KAR 5:025Credit for reinusrance."Certificate of Assuming Insurer," Form AR-1 December 95
"Certificate of Certified Reinsurer," Form CR-1 (09/19)
"Form CR-F" (09/19)
"Form CR-S" (09/19)
CHAPTER-6806 KAR 6:130Minimum standards for determining reserve liabilities and nonforfeiture values for preneed insurance.All Tables
CHAPTER-6806 KAR 6:060Reserve 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-6806 KAR 6:080Reserve standards for individual health insurance policies"Reserve Standards for Individual Health Insurance", 6/2020
CHAPTER-6806 KAR 6:120Recognition of preferred mortality tables for use in determining minimum reserve liabilities.2001 CSO Mortality Table/2001 CSO Preferred Class Structure Mortality Table
CHAPTER-6806 KAR 6:010Valuation standards; audits."1958 Commissioners Standard Ordinary Table of Mortality", 1958 "2001 Commissioner Standard Ordinary Male Composite Ultimate Mortality Table", 2001
CHAPTER-6806 KAR 6:075Valuation of life insurance policies.2001 CSO Mortality Table (2001)
Select Mortality Factors Male and Female Smoker and Non Smoker 1998 Edition
CHAPTER-6806 KAR 6:100Actuarial opinion and memorandum."Table of Reserves and Liabilities", 5/2009
CHAPTER-8806 KAR 8:010Valuation of assets on deposit. "Insurance Department Form 143, Detailed Listing of Securities Held Under Safekeeping Pursuant to KRS 304.8-095"(6/2020)
CHAPTER-9806 KAR 9:360Pharmacy Benefit Manager License."Pharmacy Benefit Manager License Application", Form PBM, 07/2020
CHAPTER-9806 KAR 9:190Disclosure requirements for financial institutions authorized to engage in insurance agency activities.FI-02, "Notice of Free Choice of Agent and Insurer", (12/2020 edition)
CHAPTER-9806 KAR 9:030Adjuster licensing restrictions"Request for Unlicensed Adjuster Representing an Insurer to Adjust Losses Resulting from a Catastrophe, Form #8307"
CHAPTER-9806 KAR 9:190Disclosure requirements for financial institutions authorized to engage in insurance agency activities.FI-03, "Financial Institution Disclosures", (8/2020 edition)
CHAPTER-11806 KAR 11:010Industrial insured, government entity insured, and exempt commercial policyholder.Form ECP-1 P & C, "Exempt Commercial Policyholder Affidavit", June, 2000 edition
Form II-1 P & C, "Industrial Insured Affidavit", June, 2000 edition
Form GEI-1 P & C, "Government Entity Insured Affidavit", June, 2000 edition
CHAPTER-12806 KAR 12:060Health Insurance replacement.APPENDIX A NOTICE TO APPLICANT REGARDING REPLACEMENT OF HEALTH INSURANCE
CHAPTER-12806 KAR 12:140Life insurance illustrations."Actuarial Standard of Practice No. 24, Compliance with the NAIC Life Insurance Illustrations Model Regulation", February 2007
CHAPTER-12806 KAR 12:170Life Insurance Disclosures "Life Insurance Buyer’s Guide, "National Association of Insurance Commissioners", 2018
CHAPTER-12806 KAR 12:080Replacement 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-12806 KAR 12:180Military 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-13806 KAR 13:130Experience modification factors for workers' compensation insurers.NAIC Buyers Guide Deferred Annuites 2013
CHAPTER-17806 KAR 17:081Minimum standards for long-term care insurance policies"Disclosures and Language for Long-term Care Policies and Certificates, HIPMC-LTC10", 09/2008
CHAPTER-17806 KAR 17:083Kentucky long-term care partnership insurance program."Important Information About Your Kentucky Long-Term Care Partnership Insurance, LTCPIP-1", 12/2008
CHAPTER-17806 KAR 17:160Creditable coverage for health insurance.Form HIPMC-CC1, "Certificate of Individual Health Plan Coverage", Kentucky Department of Insurance, January 2006 edition
CHAPTER-17806 KAR 17:240Data reporting requirements."Data Reporting Manual, HIPMC-DR-1 (06/03)
CHAPTER-17806 KAR 17:300. Provider agreement and risk-sharing agreement filing requirements"Limited Health Service Benefit Plan Summary Sheet - Form Filings HIPMC-F37", 07/18
CHAPTER-17806 KAR 17:350Guaranteed Acceptance Program (GAP) reporting requirementsGuaranteed Acceptance Program Electronic Report Format - Monthly for GAP Participating Insurers, HIPMC-GAPERF-M-1 (04/01)
CHAPTER-17806 KAR 17:270Telehealth claim forms and recordsForm HCFA - 1500, "Health Insurance Claim Form" (12-90 Edition)
CHAPTER-17806 KAR 17:570Minimum 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-17806 KAR 17:081Minimum standards for long-term care insurance policies"Rescission Reporting Form for Long-term Care Policies, HIPMC-LTC-3", 09/2008
CHAPTER-17806 KAR 17:480Uniform evaluation and reevaluation of providers."Kentucky Application for Provider Evaluation and Reevaluation", Form KAPER-1 (11/2019)
CHAPTER-17806 KAR 17:575Pharmacy benefit managers."Pharmacy Benefit Manager Annual Report," June 2017
CHAPTER-17806 KAR 17:350Guaranteed Acceptance Program (GAP) reporting requirementsGuaranteed 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-17806 KAR 17:360Prompt payment of claims."Prompt Payment Reporting Manual, DIPRPPR1",7/2018
CHAPTER-17806 KAR 17:570Minimum standards for Medicare supplement insurance policies and certificates."HL-MS-1", July 2009 edition
CHAPTER-17806 KAR 17:081Minimum 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-17806 KAR 17:450Insurance 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-17806 KAR 17:270Telehealth claim forms and recordsADA Form - J588, "Dental Claim Form" (1999 version 2000)
CHAPTER-37806 KAR 37:010Insurance holding company systems."Form A Statement Regarding the Acquisition of Control of or Merger With a Domestic Insurer," October 2014
"Form B Insurance Holding Company System Annual Registration Statement," August 2014
CHAPTER-37806 KAR 37:010Insurance holding company systems."Form A Statement Regarding the Acquisition of Control of or Merger With a Domestic Insurer," October 2014
"Form B Insurance Holding Company System Annual Registration Statement," August 2014
"Form C Summary of Changes to Registration Statement," August 2014
"Form D Prior Notice of a Transaction," August 2014
CHAPTER-37806 KAR 37:010Insurance holding company systems."Form C Summary of Changes to Registration Statement," August 2014
"Form D Prior Notice of a Transaction," August 2014
CHAPTER-38806 KAR 38:100 Risk-based capital for health organizations.RBC Health Instructions CLEAN
CHAPTER-39806 KAR 39:030Kentucky No-Fault Rejection Form.NF-1(a)(b)(c) P and C, "Kentucky No-Fault Rejection Form" (12/17)
CHAPTER-39806 KAR 39:070Proof of motor vehicle insurance."Kentucky Automobile Liability Insurance Reporting Guide", Transportation Cabinet, Department of Vehicle Regulation (Version 1.6, 8/15/2005 edition)
"Form No. TC 96-30, Motor Vehicle Insurance Agent Insurance Binder Cancellation Form (5/05 edition)"
CHAPTER-46806 KAR 46:040Forms for application and financial statements. "Form 995 - Application for Certificate of Filing As a Liability Self-Insurance Group", 7/2020
CHAPTER-46806 KAR 46:050Liability self-insurance group rate, underwriting and evidence of coverage filings.Form LSIG: F-1A P & C, "Face Sheet and Verification Form for Liability Self Insurance Groups", 7/2010;
Form LSIG: S-2 P & C, "Filing Synopsis Form", 7/2010
Form LSIG: LC-1 P & C, "Calculation of Loss Cost Multiplier", 7/2010
Form LSIG: LC-2 P & C, "Expense Constant Supplement", 7/2010
Form LSIG: EMA P & C, "E-mod Affidavit", 7/2010
CHAPTER-46806 KAR 46:040Forms for application and financial statements."Liability Self-Insurance Group Annual Statement (Blank)", 7/2020.
"Liability Self-Insurance Group Quarterly Statement (Blank)", 7/2020
"Form 101 - Trustee Confirmation of Receipt", 7/2020
CHAPTER-46806 KAR 46:050Liability self-insurance group rate, underwriting and evidence of coverage filings.Form LSIG: F-2 P & C, "Forms Index", 7/2010
Form LSIG: S-1 P & C, "Filing Synopsis for Rates and or Rules", 7/2010
CHAPTER-47806 KAR 47:010Fraud prevention.Uniform Suspected Insurance Fraud Reporting Form - 03-2019 - Clean
CHAPTER-49806 KAR 49:020Captive insurer application requirements.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)
Biographical Affidavit CI-501 (4/2001)
Captive Application for Admission CI-103 (6/2020)
Coverage, Limits and Reinsurance CI-105 (4/2001)
Application for Authorization as an Independent Certified Public Accountant for Captive Insurance Business CI-120 (6/2020)
CHAPTER-52806 KAR 52:010Forms for application, security deposits and financial statements. "Form 141 - Election Form for Designation of Custodian Bank for Safekeeping of Securities 7/2020
"Form 142 - Letter of Credit 7/2020
"Form 145 - Transaction Sheet for Securities Held Under Safekeeping with Designated Custodian Banks 7/2020
"Form 826 - Safekeeping Agreement for Workers’ Compensation Self-Insured Groups 7/2020
"Workers’ Compensation Self-Insured Group Quarterly Statement (Blank) 7/2020
"Form 102 - Trustee Confirmation of Receipt 7/2020
"Form 147 - Deposit Calculation for Workers’ Compensation Self-Insured Groups 6/2020
"Workers’ Compensation Self-Insured Group Annual Statement (Blank) 7/2020
"Form 100 - Initial Application for Certificate of Filing As a Workers’ Compensation SelfInsured Group 7/2020