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Life and Health

PERIODICALLY FILED FORMS

Note:  Life and Health Statutory Data Reporting Forms have been moved to another page on this site.


(No due date, use as needed)

Form #

Title

OIR-B2-312

Notice to Applicant Regarding Replacement of Life Insurance

OIR-B2-313

Exhibit B Comparative Information Form for Proposed Insurance

OIR-B2-1311

Individual Carriers Application to Become a Risk Assuming Carrier or a Reinsuring Carrier- Information

OIR-B2-1304

Individual Carriers Application to Modify Previous Election to Become a Risk Assuming Carrier or a Reinsuring Carrier - Information

OIR-B2-1093

Small Employer Carrier's Application To Become A Risk Assuming Carrier or A Reinsuring Carrier - Information

OIR-B2-1095

Small Employer Carrier's Application To Modify Previous Election To Become A Risk Assuming Carrier or A Reinsuring Carrier - Information

OIR-B2-1261

Election and Premium Notice Form

OIR-B2-1361

Certificate of Individual Health Coverage - Information

OIR-B2-1362

Certificate of Group Health Coverage - Information

OIR-B2-MSC

Outline of Medicare Supplement Coverage

 

SELF-FUNDED HEALTH BENEFIT PLANS

If you have any general questions about the additional forms listed immediately above, please contact:

Life and Health Product Review
(850) 413-3152