DEPARTMENT OF INSURANCE

PUBLIC PROTECTION
CABINET

Contribute to the Team Eastern Kentucky Flood Relief Fund at TeamEKYFloodReliefFund.ky.gov

DEPARTMENT OF INSURANCE

Other Entities

Workers' Compensation Self-Insured Groups - Forms

Form 145 - Transaction Sheet for Securities Held Under Safekeeping with Designated Custodian Banks - 99K

Form 800 - Service of Process - 138K

Form 141 - Workers' Compensation Self-Insured Groups Election Form for Safekeeping of Securities - 92K

Form 102 - Trustee Confirmation of Receipt for WCSIG - 102K

Form 100 - Application for WCSIG - 63K

Filings Reference Sheet for WCSIG - 47K

Form 147 - Deposit Calculation For Workers' Comp Self-Insured Groups - 89K

Form 146 - Approved Custodian Banks - 110K

Form 139 - Approved Banks for Workers' Compensation Self-Insured Groups - 78K

WCSIG Quarterly Statement (blank) - 71K

WCSIG Annual and Quarterly Statement Instructions - 83K

WCSIG Annual Statement (blank) - 120K

Form 826 - Safekeeping Agreement for Workers' Comp Self-Insured Groups - 74K

Form 821 - Instructions For Safekeeping Deposits For Workers' Compensation Self-Insured Groups - 186K

Form 142 - Letter of Credit for WCSIG - 121K

Other Insurance Entities - Forms

Service Warranty Information Sheet - 107K

SIEOA Application - 100K

Insurance Purchasing Outlet - 122K

Form 996 - Provider-Sponsored Integrated Health Delivery Network Application - 116K

Form 995 - Liability Self-Insured Groups Application - 130K

Form 750 - Advisory Organization Application - 58K

Form 107 - Application to Amend License as an Advisory Organization or Premium Finance Company - 73K

Form 360 - Registration for Service Warranty Contract Writers (Non-Auto) - 36K

Premium Finance Company License - Forms

Form 106 - Premium Finance Company Application - 183K

PF-4 - Premium Finance Company Annual Report - 352K

PF-2 - Premium Finance Company Application For Renewal - 127K

Form 505 - Premium Finance Company Survey - 52K

Form 504 - Premium Finance Company Check Remittance Form - 72K

Form 503 - Premium Finance Company Biographical Questionnaire - 155K

Form 340 - Premium Finance Company Application Checklist - 175K

Form 107 - Application to Amend License as an Advisory Organization or Premium Finance Company - 73K

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