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DEPARTMENT OF INSURANCE
Consumers
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Insurers
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Resources
Contact the Department of Insurance
Health and Life Forms and Documents
Health Form Filing Checklists
Non-Grandfathered Small Group Health Benefit (Major Medical Coverage) Plan Checklist
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Pediatric Dental Essential Health Benefit Checklist
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Provider Agreements for Limited Health Benefit Plans Checklist
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Standardized Options Silver 73 CSR Plan Checklist
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Blanket Insurance Checklist
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Date of Filing Checklist
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Non-Grandfathered Individual & Conversion Health Benefit Plan (Major Medical Coverage) Checklist
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Non-Grandfathered Large Group Health Benefit Plan (Major Medical Coverage) Checklist
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Short-Term Nursing Home Insurance Filing Checklist
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Grandfathered Individual Health Benefit Plan Checklist
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Grandfathered Large Group Health Benefit Plan Checklist
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Grandfathered Small Group Health Benefit Plan Checklist
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Individual Limited Health Benefit Plan Checklist
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Individual Non-Health Benefit Plan Checklist
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Provider Agreements for Limited Health Service Organizations Checklist
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Standardized Options Bronze Plan Checklist
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Standardized Options Gold Plan Checklist
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Standardized Options Silver 87 CSR Plan Checklist
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Standardized Options Silver 94 CSR Plan Checklist
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Standardized Options Silver Plan Checklist
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Student Health (Blanket) with EHB Checklist
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Individual Short-Term Limited Duration Plan Checklist
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General Applications Checklist
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Group Limited Health Benefit Plan Checklist
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Group Non-Health Benefit Plan Checklist
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Group and Individual Medicare Supplement Insurance Filing Checklist
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Group and Individual Medicare Supplement Insurance Filing Checklist - Attachment 1
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Long-Term Care Filing Checklist
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Provider Directory Checklist
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Provider Agreements for Health Benefit Plans Checklist
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Health Rate Filing Documents
HIPMC-R32 (07/2008) Health Benefit Plan Rate Filing
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HIPMC-R33 (12/2000) - Health Benefit Plan Regions
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HIPMC-R34 (07/2008) Attachment A - Certification
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Income and Expense Worksheet
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HIPMC-F1 2021
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HIPMC-R36 FORM 2020
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HIPMC-R-4 Individual Health Forms Actuarial Certification Form
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Form HIPMC-F11, Health Rate Summary Sheet – Form Filings
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HIPMC-RF25 (07/2008) - Basic Health Benefit Plan Summary Sheet - Form and Rate Filings
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Health Form Filing Documents
HIPMC-R1 (7-2000) - Risk-Sharing Arrangement Information Sheet
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HIPMC-F2 Health Policy Forms Filing Certification Privilege Program Form
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HIPMC-F35 - Health Benefit Plan Summary Sheet - Form Filings
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HIPMC-F1 2021
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HIPMC-RF25 (07/2008) - Basic Health Benefit Plan Summary Sheet - Form and Rate Filings
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HIPMC-F-16 Additional Health Info Request Form
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HIPMC-F37 (07/2008) - Limited Health Service Benefit Plan Summary Sheet - Form Filings
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Consumer
2025 Anthem Marketplace Service Area Map
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2025 CareSource, Molina-Passport, WellCare Marketplace Service Area Map
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2024 Anthem Marketplace Service Area Map
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2024 CareSource, Molina-Passport, WellCare Marketplace Service Area Map
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2023 Anthem Marketplace Service Area
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2023 CareSource, Molina-Passport, WellCare Marketplace Service Area
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Companies Selling In Kentucky's Individual Market
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Companies Selling Short-Term Major Medical Insurance in Kentucky
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Companies Selling Association, Large Group, Small Group and Individual Health Insurance in Kentucky
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Short-Term, Limited Duration Health Insurance
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Provider Related
Clean Claim Form
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KAPER -1 Codes Only (2019)
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KAPER-1 Part A- Application (2019)
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KAPER Part B Section 1 (2021)
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KAPER Part B Section 2 Fillable (2019)
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Kentucky Application for Provider Evaluation and Re-evaluation KAPER-1 (2019)
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TMJ Surgical Treatment Preauthorization
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TMJ Nonsurgical Treatment Preauthorization
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Insurer
HIPMC-CC1 (January 2006) - Certificate of Individual Health Plan Coverage
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HIPMC-STN-01 Outline of Coverage for Shot-term Care
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Independent Review Information - List of IRE's certified to perform external reviews
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HIPMC-MD1 (10/2000) - Medical Director Report Form
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Utilization Review Entities
2024 Utilization Management Review Guide- Full Review
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HIPMC-UR-1 - Utilization Review Registration Application
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HIPMC-UR-2 Utilization Review Annual Report
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HIPMC-MD-1 - Medical Director Form
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2020 Utilization Management Limited Self-Funded Review Guide Interactive
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Utilization Review Training FAQs
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Utilization Review Training Presentation Slides
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Meeting
Independent Review Entities
IRE Certification Review Guide
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HIPMC-IRE-1 - Application for Certification of an Independent Review Entity
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HIPMC-IRE-2 - Assignment of Independent Review Entity Form
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HIPMC-IRE-3 - External Review Decision Notification Form
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HIPMC-IRE-4 - Data Reporting For Independent Review Entities
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HIPMC-IRE-5 - Approval of an External Review Fee in excess of $800
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HIPMC-IRE-6 - External Review Information Face Sheet
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Independent Review Information - List of IRE's certified to perform external reviews
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Reporting
Prompt Pay Supporting Data Template
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Prompt Payment Spreadsheet (03/2007)
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Prompt Pay Supporting Data Instructions
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Pharmacy Benefit Manager Annual Report Instructions
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HL-MS-1 - Refund Calculation Form
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Medicare Supplement Rate Data Sheet 2010
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Service Area Expansion Enclosure
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Provider Adequacy and Accessibility Reporting
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New Service Area Enclosure
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HIPMC-BHP1 (07/2008) - Basic Health Benefit Plan Annual Report
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Data Report Capitation Payment Sheet
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Data Report Health Benefit Plan Questionnaire
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DIPR-PPR1 (07/2018) - Prompt Pay Reporting Manual
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HIPMC-LTC 11 (09/2008) - Replacement and Lapse Reporting Form
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HIPMC-LTC 3 (09/2008) - Rescission Reporting Form
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HIPMC-LTC 4 (09/2001) - Claims Denial Reporting Form
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HIPMC-DR1 - Data Reporting Manual
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HIPMC-GAP ERF-M-1 & A-1 Monthly and Annual Report Format
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HIPMC-GAP-AFF-1 (06/01) - Guaranteed Acceptance Program (GAP) Affidavit
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HIPMC-GAP-C-1GAP (12-2000) - Guaranteed Acceptance Program (GAP) Certification Form
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HIPMC-GAPQR-2 (04/01) - Supporting Insurer's and Stop-Loss Carrier's Quarterly Report
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Geo Enclosure 1 Revision 513
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Geo Enclosure 2 Revision 114
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Limited Health Service Benefit Plan Enclosure 1
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Limited Health Service Benefit Plan Enclosure 2
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HIPMC-STE-1 Step Therapy Exceptions Annual Report Instructions
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HIPMC-STE-1 Step Therapy Exception Report
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Data Reporting Template-21
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General Documents (Health)
Appealing a Denial From Your Health Benefit Plan - Expanded Version
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Appealing a Denial From Your Health Benefit Plan - A How-To Guide
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Kentucky Long-Term Care Partnership Insurance Program Implementation Update (12/2008)
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Department of Labor's Model Continuation Coverage Election Notice
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Insurance Information for Seniors
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Appendix A: Notice to Applicant Regarding Replacement of Health Insurance
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Long Term Care Form Filing Documents
LTCPIP-2- The Kentucky Long Term Care Partnership Insurance Program Notice
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LTCPIP-1 - Important Information About Your Kentucky Long-Term Care Partnership Insurance
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LTCPIP-3 - Important Notice of Offer to Exchange
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LTCPIP-4 - Long-term Care Partnership Insurance (LTCPI) Program Statement of Benefits Paid
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The Kentucky Long -Term Care Partnership Insurance Program Notice
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HIPMC-LTC 1 (09/2008) - Personal Worksheet
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HIPMC-LTC 9 (09/2008) - Notice to Applicant Regarding Replacement of Group Accident and Sickness or Long-Term Care Insurance
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HIPMC-LTC 2 (09/2008) - Potential Rate Increase Disclosure Form
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HIPMC-LTC 5 (09/2008) - Things You Should Know Before You Buy Long -Term Care Insurance
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HIPMC-LTC 6 (09/2008) - Suitability Letter
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HIPMC-LTC 7 (09/2008) - Outline of Coverage
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HIPMC-LTC 8 (09/2008) - Notice to Applicant Regarding Replacement of Ind Accident and Sickness or Long-Term Care Insurance
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HIPMC-LTC 10 (09/2008) - Disclosures and Language for Long-term Care Policies and Certificates
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Standard Benefit Plan
Kentucky Standard Health Benefit Plan (06/2011)
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Medicare Supplement Form Filing Documents
HL-MS-2 - Form for Reporting Medicare Supplement Policies
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HL-MS-3 - Disclosure Statements
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HL-MS-4 - Outline of Coverage
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Plan Benefit Chart (Apr 2018)
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HL-MS-6 - Questions for Applications
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HL-MS-7 - Statement Regarding Medicare Supplement Policies
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HL-MS-8 - Notice Regarding Replacement
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HL-MS-5 - Kentucky Medicare Supplement Comparison Statement
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Life Form Filings
Life Form Filing Process
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General Documents (Life)
2001 CSO Mortality Tables
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Notice of Rights as an Owner of a Life Insurance Policy
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Life Buyer's Guide 2011
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AIG Consumer FAQ
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NOLHGA Assumption Certificate Lincoln
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NOLHGA Generic Notice to Policyholder
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Department of Defense Instruction Number 1344.07, Personal Commercial Solicitation on DoD Installations
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Office Form B - Notice Regarding Replacement
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Office Form C - Replacement Of Life Insurance Or Annuities
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Annuity Buyer's Guide 2011
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Options When Your Group Life Coverage Ends
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Zero Premium
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Department of Defense Form 2885, Personal Commercial Solicitation Evaluation
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Office Form A - Replacement Of Life Insurance Or Annuities (Applicant and Agent)
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Life Form Filing Checklists
Accelerated Death Benefit Checklist
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Advertising Checklist
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Annuity Checklist
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Basic Application Checklist
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Group Life Insurance Checklist
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Variable Life Checklist
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Life Settlement Checklist
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Long-Term Care Riders Checklist
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Pre-Need Checklist
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Variable Annuity Checklist
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Individual Life Insurance Checklist
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Life Settlement
LS1 (7/2008) Life Settlement Provider Report - For Insureds Only
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LS2 (7/2008) Individual Mortality Report - For Insureds Only
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LS3 (7/2008) Life Settlement Provider Report - All States and Territories
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LS6 (7/2008) Life Settlement Provider Certification Form
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Life Settlement Consumer Guide
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Viatical Settlement Information Packet
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Notice 126
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LS-7 Form Settlement Disclosure
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Verification of Coverage for Life Insurance Policies
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Open Records Request
Public Access Insurance Filings for Rate, Rule, and Form Filing Search
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VISIT OTHER PPC AGENCIES