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DEPARTMENT OF INSURANCE
Consumers
Licensees
Insurers
eServices
Resources
Contact the Department of Insurance
Financial Standards Forms and Documents
General Information (Financial Standards)
Annual Statement and Other Instructions
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CI-150 - Captive RRG only - Direct Economic Impact of KY Captive During Current Reporting Year
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FAQ Regarding Insurers
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Schedule of Insurer Fees, Taxes and Deposits
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Corporate Governance Annual Disclosure 07/19
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NAIC Checklist for Health
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NAIC Checklist for Life
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NAIC Checklist for Property
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NAIC Checklist for Title
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Uniform Checklist for Reciprocal Jurisdiction Reinsurers
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Accredited and Other Approved Reinsurers List
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Certified Reinsurer Application and Forms
Annual Statement Instructions
WCSIG Annual and Quarterly Statement Instructions
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NAIC Checklist for Health
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NAIC Checklist for Life
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NAIC Checklist for Property
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NAIC Checklist for Title
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Captive Annual Statement (Blank)
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Annual Statement and Other Instructions
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Assessment Fire Annual Statement Blank
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Assessment Fire Annual Statement Instructions
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Cyber Security
Cyber Security Exemption Attestation Form 2026
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Cyber Security Compliance Attestation Form 2026
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Insurance Purchasing Outlet - Forms
HIPMC-IPO-3 (09/02) - Annual Financial Statement of Insurance Purchasing Outlet
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HIPMC-IPO-4 (09/02) - Quarterly Financial Statement of Insurance Purchasing Outlet
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HIPMC-IPO-1 (07/02) - Insurance Purchasing Outlet Application for Registration Face Sheet
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HIPMC-IPO-2 (09/02) - Annual Report on Operations of Insurance Purchasing Outlet
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Workers' Compensation Self-Insured Groups - Forms
WCSIG Annual Statement (blank)
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Filings Reference Sheet for WCSIG
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Form 139 - Approved Banks for Workers' Compensation Self-Insured Groups
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Form 821 - Instructions For Safekeeping Deposits For Workers' Compensation Self-Insured Groups
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Form 826 - Safekeeping Agreement for Workers' Comp Self-Insured Groups
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Form 100 - Application for WCSIG
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Form 800 - Service of Process
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Form 142 - Letter of Credit for WCSIG
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Form 145 - Transaction Sheet for Securities Held Under Safekeeping with Designated Custodian Banks
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Form 147 - Deposit Calculation For Workers' Comp Self-Insured Groups
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WCSIG Quarterly Statement (blank)
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Form 146 - Approved Custodian Banks
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WCSIG Annual and Quarterly Statement Instructions
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Form 102 - Trustee Confirmation of Receipt for WCSIG
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Form 141 - Workers' Compensation Self-Insured Groups Election Form for Safekeeping of Securities
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Deposits - Forms
Form 825 - Safekeeping Agreement
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Form 139 - Approved Banks for Workers' Compensation Self-Insured Groups
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Form 820 - Instructions for Safekeeping
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Form 146 Approved Custodian Banks
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Form 144 - Securities Transaction Sheet
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Form 143 6/2020
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Form 140 - Election Form for Safekeeping of Securities Pursuant to KRS 304.8-180
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External Site Information
UCAA Application
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Fraternal Societies (Foreign and Domestic)
Annual Statement and Other Instructions
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PROPERTY & CASUALTY INSURERS
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LIFE, ACCIDENT AND HEALTH/FRATERNAL INSURERS
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Health Entities
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TITLE COMPANIES
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Form 385 - Application for Fraternal Societies
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Health Entities (Foreign)
Annual Statement and Other Instructions
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Form 440 2021
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NAIC Checklist for Health
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Health Entities (Domestic)
Annual Statement and Other Instructions
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Form 460 - Schedule of Miscellaneous Investments - Annual Statement
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Form 470 - Schedule of Miscellaneous Investments - Quarterly Statement
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Form 480 - Reconciliation and Summary of Assets and Reserve Requirements
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Form 143
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Form 495 - Kentucky Supplemental Schedule
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Form 440 2021
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NAIC Checklist for Health
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Liability Self-Insured Groups
Annual Statement and Other Instructions
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PROPERTY & CASUALTY INSURERS
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LIFE, ACCIDENT AND HEALTH/FRATERNAL INSURERS
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Health Entities
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TITLE COMPANIES
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LSIG Annual Statement Instructions
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LSIG Annual Statement Blank
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LSIG Quarterly Statement Instructions
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LSIG Quarterly Statement Blank
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Form 101 - Trustee Confirmation of Receipt for LSIG
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Form 995 - Liability Self-Insured Groups Application
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Life, Accident and Health (Foreign)
Annual Statement and Other Instructions
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Form 440 2021
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NAIC Checklist for Life
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Life, Accident and Health (Domestic)
Annual Statement and Other Instructions
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Form 470 - Schedule of Miscellaneous Investments - Quarterly Statement
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Form 480 - Reconciliation and Summary of Assets and Reserve Requirements
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Form 143
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Life PBR Statement of Exemption
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NAIC Checklist for Life
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Form 460 - Schedule of Miscellaneous Investments - Annual Statement
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Form 450 - Affidavit Covering Finance Committee
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Property & Casualty (Domestic)
Annual Statement and Other Instructions
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Form 470 - Schedule of Miscellaneous Investments - Quarterly Statement
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Form 143
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NAIC Checklist for Property
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Form 460 - Schedule of Miscellaneous Investments - Annual Statement
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Form 480 - Reconciliation and Summary of Assets and Reserve Requirements
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Property & Casualty (Foreign)
Annual Statement and Other Instructions
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NAIC Checklist for Property
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Title (Foreign)
Annual Statement and Other Instructions
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NAIC Checklist for Title
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Assessment Fire
Assessment Fire Annual Statement Instructions
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Assessment Fire Annual Statement Blank
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Risk Retention Groups, Accredited Reinsurers
Form 365 - Registration for Accredited Reinsurers
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Other Approved Reinsurers, Surplus Lines
Form 800 - Service of Process
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Form 916 - Surplus Lines Insurer Information Sheet
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Form 370 - Registration for Other Approved Reinsurers
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Captive Insurer - Forms
CI-150 - Captive RRG only - Direct Economic Impact of KY Captive During Current Reporting Year
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CI-105 Captives - Coverage, Limits and Reinsurance
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CI-140 - Confirmation Form for Captives
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CI-501 Biographical Affidavit
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Captive Fees, Taxes and Capitalization
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Form D for Captives
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Captive Annual Statement (Blank)
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CI-120 - Captives - Application for Authorization as Independent CPA for Captive Insurance Business
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Form 8301 - Individual Application
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CI-130 - Captives - Irrevocable Letter of Credit
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CI-110 Captive - Application for Authorization to certify loss reserves and loss expense reserves for captives
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CI-103 Captive Insurer Application
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State Filing Fees - Captive Check Remittance Form (Domestic)
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Miscellaneous Forms
Form 501 Revised
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Form 600 - Life and Health Guaranty Acceptance
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Form 610 - Property and Casualty Guaranty Acceptance
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Form 800 - Service of Process
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Form 700 - No-Fault Form
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Other Insurance Entities - Forms
Form 107 - Application to Amend License as an Advisory Organization or Premium Finance Company
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Form 750 - Advisory Organization Application
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Insurance Purchasing Outlet
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Form 360 - Registration for Service Warranty Contract Writers (Non-Auto)
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Form 996 - Provider-Sponsored Integrated Health Delivery Network Application
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SIEOA Application
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Service Warranty Information Sheet
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Form 995 - Liability Self-Insured Groups Application
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Risk Retention Groups (Foreign) - Forms
Form 955 - Liability Risk Retention Groups Summary
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Form 970 - Attorney Appointment: Risk Retention Groups
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Form 960 - Application for Risk Retention Groups
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Premium Finance Company License - Forms
Form 107 - Application to Amend License as an Advisory Organization or Premium Finance Company
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Form 106 - Premium Finance Company Application
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Form 340 - Premium Finance Company Application Checklist
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PF-4 - Premium Finance Company Annual Report
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Form 504 - Premium Finance Company Check Remittance Form
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Form 505 - Premium Finance Company Survey
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PF-2 - Premium Finance Company Application For Renewal
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Form 503 - Premium Finance Company Biographical Questionnaire
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Holding Company Form Templates
Form A: Statement Regarding the Acquisition of Control of or Merger With a Domestic Insurer
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Form D: Prior Notice of a Transaction
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Form F: Enterprise Risk Report
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Form B: Insurance Holding Company System Annual Registration Statement
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Form C: Summary of Changes to Registration Statement
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Form E: Pre-Acquisition Notification Form Regarding the Potential Competitive Impact of a Proposed Merger or Acquisition by a Non-Domiciliary Insurer Doing Business in This State or by a Domestic Insurer
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Motor Vehicle Self-Insured
Application for Motor Vehicle Self-Insurance
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Motor Vehicle Self-Insured Instructions
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Kentucky Insurance Arbitration Association Membership Letter and Application
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Self-Insured Quarterly Report
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