Company Licensing Forms
The Insurance Company Licensing Information Page provides access to the following forms:
- Burial Agent Appointment Form
- Cancellation Form
- Company Authorized Signature Form
- Company License Amendments
- Fraternal Agent Appointment Form
- Life Type Producer Appointment Form
- NAIC Uniform Certificate of Authority Application
- Professional Bail Agent: Limited Surety Appointment Form
- Property and Casualty Type Appointment Form
- Title Agent Appointment Form
Direct Placement/Self-Insurance Form
The Direct Placement/Self-Insurance Form is on the General Company Information Page.
Life, Accident, and Health Forms
The Life, Accident and Health Form and Rate Filing Information Page provides access to the following forms:
- General Information
- NAIC Universal Transmittal Form
- NAIC Product Coding Matrix
- Current Requirements – Item Descriptions and related attachments
- MS State Specific Information – for completing Transmittal Document
- MS Filing Fee Form
- MSRATE – rate filing instructions
- RII 7/02 – rate increase information form
- Current Submission Requirements For
- Accident and Health
- Long Tem Care
- Medicare Supplement
- Credit Life, Credit Accident & Health
- Industrial Life, Industrial Accident & Health
- Life
Property and Casualty Forms
The Property and Casualty Rate Filing Information Page provides access to the following forms:
- Loss Cost Filing Procedures (October 19, 1990)
- Mississippi Insurer Rate Filing
- Adoption of Rate Service Organization
- Prospective Loss Costs
- MDOI Property/Casualty Rate Filing Exhibits
- Exhibit A - Statewide Average Rate Level Information
- Exhibit B - Historical Experience
- Exhibit C - Expense Information
- Exhibit D - Derivation of Target Underwriting Profit Provision
- MDOI Property/Casualty Rate Filing - General Submission Instructions
- Mississippi Expense Constant Supplement
- Mississippi Ratemaking Worksheet
- Mississippi Property and Casualty Filing Fee Form
- NAIC Product Coding Matrix
- NAIC Universal Transmittal Forms
- New Required form for all P&C Rate or Rule filings (January 8, 2007)
- Reference Filing Adoption Form
- Speed to Market Checklist
- Summary of Supporting Information Form / Calculation of Company Loss Cost Multiplier
Risk Retention and Risk Purchasing Group Checklists
The Risk Retention and Risk Purchasing Group Information provides access to the following forms:
- Purchasing Group Registration Checklist
- Risk Retention Group Registration Checklist
Statement Filing Requirements
The Statement Filing Requirements Page provides access to the following forms:
- Accredited Reinsurer Annual Statement Filing Requirements (pdf)
- Alien Surplus Lines Companies Annual Filing Requirements (pdf)
- Automobile Club Annual Statement Filing Requirements (pdf)
- Burial Associations Annual Statement Filing Requirements (pdf)
- Foreign Surplus Lines Companies Annual Statement Filing Requirements (pdf)
- Fraternal Societies Annual Statement Filing Requirements (pdf)
- Health Insurers Annual Statement Filing Requirements (pdf)
- Life Health and Accident Companies Annual Statement Filing Requirements (pdf)
- Pharmacy Benefit Managers Filing Requirements (pdf)
- Property Casualty Companies Annual Statement Filing Requirements (pdf)
- Risk Retention Groups Annual Statement Filing Requirements (pdf)
- Third Party Administrator Annual Statement Filing Requirements (pdf)
- Title Companies Annual Statement Filing Requirements (pdf)
- Trusteed Reinsurer Annual Statement Filing Requirements (pdf)
Tax Filing Forms
The Tax Filing Forms Page provides access to the following forms:
- Direct Placement/Self Insurance Premium Filing Form
- Purchasing Group Reporting Form
- Annual Risk Purchasing Group / Risk Retention Group Premium Filing Form
- Risk Retention Group Reporting Form
Factory-Built Homes/Modular Homes Forms
The Factory-Built Homes/Modular Homes Page provides access to the following forms:
- Installation Decals Order Form
- Installation Property Locator Forms:
- Installer/Transporter
- Retailer/Developer
- MH-1 Consumer Complaint Form
- Monthly Production Report Modular Building Units or Components Form
- Regulation ME-2007-3: Rules and Regulations for the Uniform Standards Code for the Factory-Built
Homes Law as Related to Modular Homes
- Regulation MH-5: Rules and Regulations, Uniform Standards Code for the Factory-Built Homes Law
- Request for Data Plates Modular Housing Building Unit
- Request for Plan Review Modular Housing
- Sales and Set-up Educational Seminar Schedule and Registration
- Truck Decals Order Form
- Application for License for Modular Home Contractor
- Application for License for Retailers of Factory-Built Manufactured Movable Homes
- Application for License for Independent Contractor Installer/Transporter of Factory-Built Manufactured Movable Homes
- Application for License for Temporary Independent Contractor Installer/Transporter of Factory-Built Manufactured Movable Homes
- Application for License for Promotional Event Retailer of Factory-Built Manufactured Movable Homes
- Application for License for Developer of Factory-Built Manufactured Movable Homes
- Application for License for Manufacturers of Hud Factory-Built Manufactured Movable Homes
- Application for License for Manufacturers of Factory-Built Re-locatable (Modular) Homes
- Application for License for Developers of Factory-Built Re-locatable (Modular) Homes
Fire Code Enforcement Forms
The Fire Code Enforcement Page provides access to the following forms:
- Rules and Regulations, Mississippi Fire Prevention Code
- Draft: Rules and Regulations, Mississippi Fire Prevention Code (6/27/06)
Fire Investigations Forms
The Fire Investigations Page provides access to the following forms:
- Fire Damage Registry Form
Fire Safety Education Forms
The Fire Safety Education Page provides access to the following forms:
- Burn Injury Report
- Fire Death\Injury Form
Fire Services Development Forms
The Fire Services Development Page provides access to the following forms:
- U.S. Fire Administration - Firefighter Investment Response Enhancement Grants Program
Liquefied Compressed Gas Forms
The Liquefied Compressed Gas Page provides access to the following forms:
- Funding Request Policies and Procedures
- Funding Request Form
- Mississippi Liquefied Compressed Gas Board Application for Permit, Class 1-10
- Guidelines and Procedures
- Mississippi Code Ann. § 75-57-1 through 75-57-119
Pyrotechnics Forms
The Pyrotechnics Page provides access to the following forms:
- Public Fireworks Display Permit Application
Residential Electronic Protection Systems Forms
The Residential Electronic Protection Systems Page provides access to the following forms:
- EP-2006-1 Mississippi Residential Electronic Protection Licensing Act Rules and Regulations
- Residential Electronic Protection Licensing Application
- Residential Electronic Protection Notification Form
- Mississippi Residential Electronic Protection Systems Investigation Request Form
Producer Licensing Forms
The Producer Licensing Page provides access to the following forms:
Individual Licensing Forms
- Life, Accident and Health Type
- Life, Accident, and Health
- Credit LAH
- Industrial LAH
- Variable Contracts
- HMO Producer
- Fraternal (Appointment Only)
- Fire and Casualty Type
- Property and Casualty
- Property and Casualty Solicitor
- Industrial Fire
- Credit Property
- Trip, Accident and Baggage
- Surplus Lines
Entity Licensing Forms
- Life, Accident and Health
- Property and Casualty
Adjuster Licensing Forms
The Adjuster Licensing Page provides access to the following forms:
Individual Licensing Forms
- Independent Adjuster
- Emergency
- Trainee
- Public Adjuster
- Emergency Public Adjusters
- Public Adjuster Trainee
- Public Adjuster Surety Bond
- Public Adjuster E&O Coverage Certification
Entity Licensing Forms
- Independent Adjuster Entity
- Public Adjuster Entity
Additional Individual License Types Forms
The Additional Individual License Types Page provides access to the following forms:
Individual Licensing Forms
- Automobile Club
- Bail Agent, Professional
- Bail Enforcement or Soliciting Agent
- Personal Surety
- Limited/Personal Surety
- Limited Surety
- Burial Agents
- Legal
- Reinsurance Intermediary Managers/Brokers
- Risk Retention Agent
- Surplus Lines
- Title
- Viatical Settlement Representative or Broker
Additional Entity License Types Forms
The Additional Entity License Types Page provides access to the following forms:
Entity Licensing Forms
- Auto Club
- Managing General Agent
- Supervising General Agent
- Third Party Administrator
- Reinsurance Intermediary Manager
- Viatical Settlement Provider
- Viatical Settlement Entity Representative or Broker
- NAIC Business Entity Form
- NAIC Uniform Service of Process Form