• FIS 0174  Accredited or Trusteed Reinsurer Certificate of Assuming Insurer (AR-1 Form)

• FIS 0406 and FIS 0407 

• FIS 0409 

• NAIC Uniform Continuing Education Reciprocity Course Filing Form (CER)

• FIS 2214 Captive Insurer Application  Includes supporting forms and instructions to make application for a Captive Insurer limited certificate of authority.

• Annual Reporting for Captive Insurance Companies

• Financial Statement Instruction Booklets and Forms UPDATED 1/3/2013-Use this link for complete form and instruction packets.

• Life, Accident & Health Insurers/Fraternal Benefit Societies/United States Branches of Non-US Insurers

• Property and Casualty/Title Insurers/United States Branches of Non-US Insurers

• Health Maintenance Organizations/Alternative Financing and Delivery Systems/Nonprofit Health Care Corporations/Dental Service Corporations

• Checklists of Financial Form Filings

• Instructions  For Application for Registration

• FIS 0233  Application for Foreign Risk Retention Group Registration

• FIS 0260Risk Retention Group Premium and Tax is now filed electronically through NAIC OPTins

• FIS 0234  Consent to Service - Foreign Risk Retention Group

• FIS 0235  Foreign Risk Retention Group Registration Fee Card

• FIS 0361  Affiliate Statement

• FIS 0364  Report of Operations

• Michigan Network Adequacy Guidance 

• Michigan Network Data Template Instructions 

• Michigan Network Data Template - UPDATED 4/26/13 

UPDATED 4/26/13  [The Michigan Network Data Template has been updated to include General Dentistry as a provider subspecialty on the Network Data worksheet.  Issuers who have begun to complete the previous version may use the template’s previous version in its SERFF submission.  In that case, if a provider type falls under the General Dentistry subspecialty then the issuer should categorize the provider as Other.]

• Network Adequacy - Michigan Service Area Maps

• HMO/AFDS Application Instructions, Exhibits and Attachments 

• FIS 0273  HMO/AFDS Application for Certificate of Authority

• FIS 0274  Appointment for Authorized Representative

• FIS 0284  Model Trust Indenture

• FIS 0285  Deposit Instructions (HMO)

• Electronic Resident and Non-Resident Licensing applications

• Application for Written Consent to Engage in the Business of Insurance  Pursuant to 18 USC Section 1033 and 1034

• FIS 0200  Insurance Business Entity Affiliate Disclosure

• FIS 0201  dba Registration

• FIS 0242  Appointment/Cancellation of Managing General AGENT or AGENCY (combines and replaces form FIS 0243)

• FIS 0261 Insurance License Document Request

• Address Change Request for all individual licensees Any non-resident adjuster must have only one home state license or must use form FIS 0262 (below).

• FIS 0262  Name change - for all licensees. Address change - must be used by agencies and may be used by individual licensees.

• FIS 2268  Branch Office Registration form

• FIS 0066  Amendment or Restatement of Michigan Articles of Incorporation Form and Checklist

• FIS 0144  Request for Determination of Exemption from Requalification Form

• FIS 0169  Articles of Incorporation

• FIS 0170  Michigan Auto Certification

• FIS 0171  Report of Insurers in the Holding Company

• FIS 0278  Medicaid Clean Claim Report

• FIS 0279  Annual Notice of Medicaid Claims Defects

• FIS 0284  Clean Claim Report

• FIS 0308  Report of Multiple Medicare Supplement Coverage in Force for Michigan Residents

• FIS 0318  Complaint and Grievance Summary for Health Carriers. FIS 319 was merged into FIS 0318.

• FIS 0376  Fire Insurance Withholding Program - Enrollment Requirements

• FIS 0378  Auto Insurance Fire Loss - Enrollment Requirements

• FIS 0425  Oath of Director of a Michigan Domestic Insurer

• FIS 0810  Application for Authority to Purchase Discretionary Group Life Insurance

• FIS 0983  Long-Term Care Insurance Annual Sales Report

• Instructions

• Form A  Statement Regarding the Acquisition of Control of or Merger with a Domestic Insurer

• Form B  Insurance Holding Company System Annual Registration Statement

• Form C  Summary of Registration Statement

• Form D  Prior Notice of a Transaction

• MEWA application filing package  includes all forms and instructions except Exhibit 1

• MEWA Pro Forma Balance Sheet  (Exhibit 1)

• Public Employer Pool Plan (Pool) application filing package  Includes all forms and instructions except Exhibit 1

• Pool Pro Forma Balance Sheet  (Exhibit 1)

• FIS 0359  Purchasing Group Application for Registration

• FIS 0255Report of Insurance Purchased From an Unauthorized Insurer is now filed electronically through NAIC OPTins. One-time filers may use FIS 0255.

• FIS 0362  Annual Renewal Report for Purchasing Groups

• FIS 0363  Change in Registration for Purchasing Groups

• FIS 0364  Report of Operations

• FIS 0365  Consent to Service - Purchsing Groups

• FIS 0845  Reinsurance Intermediary Manager Michigan License Application

• FIS 2274  Reinsurance Intermediary Broker Application

• FIS 0846  Consent to Service - Non-Resident Reinsurance Intermediary Manager

• On January 1, 2013, the Office of Financial and Insurance Regulation (OFIR) assumed responsibility for the licensing and administration of the motor vehicle self-insurance program in accordance with Public Act No. 204 of 2012.

• Application for Self-Insurance Checklist 

• FIS 2271  Application for Self-Insurance Certificate

• FIS 2260  Application for Verifying Eligiblity as Surplus Lines Insurer

• FIS 0255Report of Insurance Purchased From an Unauthorized Insurer is now filed electronically through NAIC OPTins. One-time filers may use FIS 0255.

• FIS 0269Report of Transaction with an Unauthorized Insurer Not Recognized as Eligible is now filed electronically through NAIC OPTins

• FIS 0270Surplus Lines Agent Semi-Annual Report of Michigan Premiums and Tax is now filed electronically through NAIC OPTins

• FIS 0849  Application Checklist for Third Party Administrators

• FIS 0861  Third Party Administrator Application for Certificate of Authority

• FIS 0862  Third Party Administrator Affiliation Statement

• FIS 0863  TPA Fee Processing Card

• FIS 0850  Financial Statement for Third Party Administrators

• FIS 0865  TPA Jurat Page for Annual Renewal

• FIS 0860  Consent to Service - Third Party Administrator

• Application Form

• Michigan-Specific Application Checklist and Forms

• Schedule of Company Fees, Taxes and Deposits