CID: Forms and Applications
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Forms and Applications

 
 
 
Licensee Forms and Applications:
KEY
I  Individual License Forms and Applications
BE  Business Entity Forms and Applications

I BE
Bail Bond Agent (Surety) Application I BE
Bail Bond Agent Appointment Affidavit
Bail Bond Agent (Surety) Replacement Renewal Form (available one month prior to license expiration date)
Bail Bond Certification - Online (save your confirmation email as your record)
 I
Bail Bond Surety Company Annual Report
Casualty Claim Adjuster Application I BE
Casualty Claim Adjuster Replacement Renewal Form
Certification and Clearance Forms RESIDENT ONLY
     (Clearance Letter will cancel your Connecticut license and all company appointments)
I BE
Certified Insurance Consultant Application (THIS IS NOT A PRODUCER)
 I BE
Certified Insurance Consultant Replacement Renewal Form (available one month prior to license expiration date)
Change in License Information Electronic Form I BE
Duplicate License Request
 I BE
Duplicate License Request Form (Bail Bonds Licensee Only) I BE
Fraternal Agent License/Appointment Application (Fraternal Society Use Only)
 I  
Fraternal Agent License/Appointment Cancellation Notice (Fraternal Society Use Only)
 I  
License Cancellation/Termination Form I BE
Life Producer Registration to Act as a Life Settlement Broker I
Life Settlement Broker Application I BE
Life Settlement Broker Biographical Affidavit I
Life Settlement Provider Application BE
Life Settlement Provider Renewal Application BE
Medical Discount Plan License Application BE
Medical Discount Plan License Renewal BE
Motor Vehicle Physical Damage Appraiser (MVPD) Application I BE
Motor Vehicle Physical Damage Appraiser Replacement Renewal Form
Pharmacy Benefits Manager (PBM) Initial Application for a Certificate of Registration BE
Pharmacy Benefits Manager (PBM) Renewal Application for a Certificate of Registration BE
Pharmacy Benefits Manager (PBM) Exemption Form BE
Preferred Provider Network License Application BE
Preferred Provider Network License Renewal BE
Premium Finance Company Application   BE
Premium Finance Company Renewal Application BE
Producer License Application - Resident & Non-Resident (NIPR) I BE
Producer License Application - Resident Only (CID) I BE
Producer Renewal - Resident & Non-Resident
       (Before selecting I or BE, please read the Producer Renewal Information and Producer Renewal Notification)
 I BE
Public Insurance Adjuster Application I BE
Reinsurance Intermediary Application (for Brokers and Managers) I BE
Reinsurance Intermediary Power of Attorney (Nonresident Corporation) BE
Reinsurance Intermediary Power of Attorney (Nonresident Non-Corporation) BE
Reinsurance Intermediary Power of Attorney (Nonresident Individual) I
Rental Car Company Permit Application BE
Surplus Lines Affidavit I BE
Surplus Lines Insurance Broker Application I BE
Surplus Lines Insurance Broker Replacement Renewal Form (available one month prior to license expiration date)
Surplus Lines Tax Return Form I BE
Termination "For Cause" Form I BE
Title Agent: License not available in Connecticut refer to Connecticut General Statute §38a-401
Third Party Administrator (TPA) Annual Report
Third Party Administrator (TPA) License Application
 BE
Third Party Administrator (TPA) Registration (Business Entity ONLY) BE
Utilization Review Company License Application
BE
 
 
 
Insurer Forms and Applications:
Accredited Reinsurers:
AR1 Form - Certificate of Assuming Insurer (PDF 25 kb)
Power of Attorney Form (PDF 40 kb)
Annual Financial Filing Requirement: Retention of Assets Statement (PDF 79 kb)
Fraternal Societies (PDF)
Health Insurers (PDF)
Life, Accident and Health Insurers (PDF)
Property and Casualty Insurers (PDF)
Title Companies (PDF)
2013 Consumer Report Card Survey - Cover Letter (PDF) MCR
2013 Consumer Report Card Survey - Part 1 (Word Document & PDF form)
2013 Consumer Report Card Survey - Part 2 (Word Document & PDF form)
2013 Consumer Report Card Addendum (all networks) (Word Document & PDF form)
2013 Consumer Report Card Survey – Network Adequacy Certification (Word Document & PDF form)
CT Surety Liquidation Bond Loss Claims Form
Health Care Center Insurance a/k/a HMO (Domestic Only) Application
Insurance Company License (Domestic) Application
Insurance Company License (Foreign) Application
Insurance Company Registration (Surplus Lines) Application
Insurance Fraud Report Instructions
 
Annual Insurance Fraud Report:
Insurance Fraud Referral Form (RTF form - fill-in Format 85 kb) or (PDF form - 43 kb)
Managing General Agent Application
Property & Casualty Forms Checklists
Professional Employer Organization Annual Certification (PDF 26 kb)
Request for Rescission, Cancellation or Limitation of a Health Insurance Policy
Rental Car Company Appointment Application
 
 
 
 
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Content Last Modified on 5/14/2013 3:52:31 PM