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DEPARTMENT OF INSURANCE
Consumers
Licensees
Insurers
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Resources
Contact the Department of Insurance
Financial Standards Forms and Documents
General Information (Financial Standards)
FAQ Regarding Insurers
- 118K
Corporate Governance Annual Disclosure 07/19
- 21K
Accredited and Other Approved Reinsurers List
- 29K
CI-150 - Captive RRG only - Direct Economic Impact of KY Captive During Current Reporting Year
- 27K
Schedule of Insurer Fees, Taxes and Deposits
- 156K
Annual Statement and Other Instructions
- 235K
Certified Reinsurer Application and Forms
Uniform Checklist for Reciprocal Jurisdiction Reinsurers
- 257K
Annual Statement Instructions
WCSIG Annual and Quarterly Statement Instructions
- 83K
NAIC Checklist for Health
- 241K
NAIC Checklist for Life
- 298K
NAIC Checklist for Property
- 253K
NAIC Checklist for Title
- 219K
Captive Annual Statement (Blank)
- 73K
Annual Statement and Other Instructions
- 235K
Assessment Fire Annual Statement Blank
- 166K
Assessment Fire Annual Statement Instructions
- 748K
Insurance Purchasing Outlet - Forms
HIPMC-IPO-4 (09/02) - Quarterly Financial Statement of Insurance Purchasing Outlet
- 90K
HIPMC-IPO-3 (09/02) - Annual Financial Statement of Insurance Purchasing Outlet
- 78K
HIPMC-IPO-1 (07/02) - Insurance Purchasing Outlet Application for Registration Face Sheet
- 179K
HIPMC-IPO-2 (09/02) - Annual Report on Operations of Insurance Purchasing Outlet
- 85K
Workers' Compensation Self-Insured Groups - Forms
WCSIG Annual and Quarterly Statement Instructions
- 83K
WCSIG Annual Statement (blank)
- 120K
Form 102 - Trustee Confirmation of Receipt for WCSIG
- 102K
Form 141 - Workers' Compensation Self-Insured Groups Election Form for Safekeeping of Securities
- 92K
Form 147 - Deposit Calculation For Workers' Comp Self-Insured Groups
- 89K
WCSIG Quarterly Statement (blank)
- 71K
Form 142 - Letter of Credit for WCSIG
- 121K
Form 145 - Transaction Sheet for Securities Held Under Safekeeping with Designated Custodian Banks
- 99K
Form 100 - Application for WCSIG
- 63K
Filings Reference Sheet for WCSIG
- 47K
Form 826 - Safekeeping Agreement for Workers' Comp Self-Insured Groups
- 74K
Form 146 - Approved Custodian Banks
- 110K
Form 821 - Instructions For Safekeeping Deposits For Workers' Compensation Self-Insured Groups
- 186K
Form 139 - Approved Banks for Workers' Compensation Self-Insured Groups
- 78K
Form 800 - Service of Process
- 138K
Deposits - Forms
Form 143 6/2020
- 14K
Form 139 - Approved Banks for Workers' Compensation Self-Insured Groups
- 78K
Form 820 - Instructions for Safekeeping
- 65K
Form 140 - Election Form for Safekeeping of Securities Pursuant to KRS 304.8-180
- 112K
Form 825 - Safekeeping Agreement
- 118K
Form 146 Approved Custodian Banks
- 111K
Form 144 - Securities Transaction Sheet
- 60K
External Site Information
UCAA Application
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Fraternal Societies (Foreign and Domestic)
Form 385 - Application for Fraternal Societies
- 37K
Annual Statement and Other Instructions
- 235K
Health Entities (Foreign)
Annual Statement and Other Instructions
- 235K
NAIC Checklist for Health
- 241K
Form 440 2021
- 85K
Health Entities (Domestic)
Form 460 - Schedule of Miscellaneous Investments - Annual Statement
- 24K
Form 470 - Schedule of Miscellaneous Investments - Quarterly Statement
- 26K
Form 480 - Reconciliation and Summary of Assets and Reserve Requirements
- 28K
NAIC Checklist for Health
- 241K
Form 495 - Kentucky Supplemental Schedule
- 35K
Annual Statement and Other Instructions
- 235K
Form 440 2021
- 85K
Form 143
- 14K
Liability Self-Insured Groups
Form 101 - Trustee Confirmation of Receipt for LSIG
- 80K
LSIG Quarterly Statement Blank
- 73K
Form 995 - Liability Self-Insured Groups Application
- 130K
LSIG Annual Statement Blank
- 104K
LSIG Annual Statement Instructions
- 40K
LSIG Quarterly Statement Instructions
- 28K
Life, Accident and Health (Foreign)
NAIC Checklist for Life
- 298K
Form 440 2021
- 85K
Annual Statement and Other Instructions
- 235K
Life, Accident and Health (Domestic)
Form 460 - Schedule of Miscellaneous Investments - Annual Statement
- 24K
Form 470 - Schedule of Miscellaneous Investments - Quarterly Statement
- 26K
Form 480 - Reconciliation and Summary of Assets and Reserve Requirements
- 28K
Annual Statement and Other Instructions
- 235K
Form 143
- 14K
Life PBR Statement of Exemption
- 123K
NAIC Checklist for Life
- 298K
Form 450 - Affidavit Covering Finance Committee
- 14K
Property & Casualty (Domestic)
Form 460 - Schedule of Miscellaneous Investments - Annual Statement
- 24K
Form 470 - Schedule of Miscellaneous Investments - Quarterly Statement
- 26K
NAIC Checklist for Property
- 253K
Form 143
- 14K
Annual Statement and Other Instructions
- 235K
Form 480 - Reconciliation and Summary of Assets and Reserve Requirements
- 28K
Property & Casualty (Foreign)
NAIC Checklist for Property
- 253K
Annual Statement and Other Instructions
- 235K
Title (Foreign)
Annual Statement and Other Instructions
- 235K
NAIC Checklist for Title
- 219K
Assessment Fire
Assessment Fire Check Remittance Form
- 90K
Assessment Fire Annual Statement Instructions
- 649K
Assessment Fire Annual Statement Blank
- 168K
Risk Retention Groups, Accredited Reinsurers
Form 365 - Registration for Accredited Reinsurers
- 66K
Other Approved Reinsurers, Surplus Lines
Form 800 - Service of Process
- 138K
Form 370 - Registration for Other Approved Reinsurers
- 136K
Form 916 - Surplus Lines Insurer Information Sheet
- 126K
Surplus Lines Carriers Eligibility Requirements for Kentucky
- 44K
OAR, SL Check Remittance Form
- 88K
Captive Insurer - Forms
CI-150 - Captive RRG only - Direct Economic Impact of KY Captive During Current Reporting Year
- 27K
CI-105 Captives - Coverage, Limits and Reinsurance
- 12K
CI-140 - Confirmation Form for Captives
- 102K
CI-501 Biographical Affidavit
- 57K
Captive Fees, Taxes and Capitalization
- 156K
Form D for Captives
- 240K
Captive Annual Statement (Blank)
- 69K
CI-120 - Captives - Application for Authorization as Independent CPA for Captive Insurance Business
- 40K
Form 8301 - Individual Application
- 289K
CI-130 - Captives - Irrevocable Letter of Credit
- 44K
CI-110 Captive - Application for Authorization to certify loss reserves and loss expense reserves for captives
- 40K
CI-103 Captive Insurer Application
- 44K
State Filing Fees - Captive Check Remittance Form (Domestic)
- 18K
Miscellaneous Forms
Form 501 Revised
- 481K
Form 600 - Life and Health Guaranty Acceptance
- 45K
Form 610 - Property and Casualty Guaranty Acceptance
- 56K
Form 800 - Service of Process
- 138K
Form 700 - No-Fault Form
- 135K
Other Insurance Entities - Forms
Form 107 - Application to Amend License as an Advisory Organization or Premium Finance Company
- 73K
Form 750 - Advisory Organization Application
- 58K
Insurance Purchasing Outlet
- 122K
Form 360 - Registration for Service Warranty Contract Writers (Non-Auto)
- 158K
Form 996 - Provider-Sponsored Integrated Health Delivery Network Application
- 116K
SIEOA Application
- 100K
Service Warranty Information Sheet
- 126K
Form 995 - Liability Self-Insured Groups Application
- 130K
Risk Retention Groups (Foreign) - Forms
Form 955 - Liability Risk Retention Groups Summary
- 128K
Form 970 - Attorney Appointment: Risk Retention Groups
- 144K
Form 960 - Application for Risk Retention Groups
- 275K
Premium Finance Company License - Forms
Form 107 - Application to Amend License as an Advisory Organization or Premium Finance Company
- 73K
Form 106 - Premium Finance Company Application
- 183K
Form 340 - Premium Finance Company Application Checklist
- 175K
PF-4 - Premium Finance Company Annual Report
- 352K
Form 504 - Premium Finance Company Check Remittance Form
- 72K
Form 505 - Premium Finance Company Survey
- 52K
PF-2 - Premium Finance Company Application For Renewal
- 127K
Form 503 - Premium Finance Company Biographical Questionnaire
- 155K
Holding Company Form Templates
Form A: Statement Regarding the Acquisition of Control of or Merger With a Domestic Insurer
- 118K
Form D: Prior Notice of a Transaction
- 109K
Form F: Enterprise Risk Report
- 34K
Form B: Insurance Holding Company System Annual Registration Statement
- 115K
Form C: Summary of Changes to Registration Statement
- 96K
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
- 91K
Motor Vehicle Self-Insured
Application for Motor Vehicle Self-Insurance
- 376K
Motor Vehicle Self-Insured Instructions
- 101K
Kentucky Insurance Arbitration Association Membership Letter and Application
- 91K
Self-Insured Quarterly Report
- 134K
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