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Licensing and Registration - Forms & Information

On this page: Adjusters | Agencies/Business Entities | Consultants | Employee Leasing | Managing General Agent | Medical Utilization Review | Multiple-Employer Welfare Arrangements | Pharmacy Benefits Manager | Portable Electronic Device Insurance Vendor Preferred Provider Arrangement | Producer | Reinsurance Intermediary | Risk Purchasing Group | Risk Retention Group | Self Insurance for Workers' Comp | Service Contract Provider/Administrator | Special Purpose Reinsurance Vehicles | Structured Settlement Transferree | Third Party Administrator | Viatical and Life Settlement |

 

The following documents have been developed in either Microsoft Word, Microsoft Excel, or Adobe PDF format.

Get the Adobe Acrobat Reader to access PDF files.

Adjusters

• Definition
• Application - Word or Adobe PDF
• Exam Information

Agencies/Business Entities

• Definition
• Application
• Branch Location Registration Form - Word or Adobe PDF
• Business entity Termination of License or Branch Registrations - Word or Adobe PDF
• Motor Vehicle Rental Company Application - Word or Adobe PDF

Consultants

• Definition
• Application - Word or Adobe PDF
• Exam Information
• Property and Casualty Agreement Form - Word or Adobe PDF
• Life and Health Agreement Form - Word or Adobe PDF

Employee Leasing Company (PEO)

• Registration Information/Checklist - Word or Adobe PDF
• Registration Form - Word or Adobe PDF

Managing General Agent

• Registration Information - Word or Adobe PDF
• Registration Application - Word or Adobe PDF
• Application Check List - Word or Adobe PDF
• Bond - Word or Adobe PDF
• Contract Compliance Form - Word or Adobe PDF
• Reporting Form - Word or Adobe PDF
• Title 24-A M.R.S.A. Chapter 16 Subchapter 8

Medical Utilization Review

• Application - Word or Adobe PDF
• Initial License Information
• License Renewal Information
• Annual Evaluation Information Reporting Form - Excel or Adobe PDF

Multiple-Employer Welfare Arrangements

• Application Requirements - Word or Adobe PDF
• Application Requirements Specific to Employee Leasing Companies - Word or Adobe PDF

Pharmacy Benefits Manager

• Application - Word or Adobe PDF
• Title 24-A §1913

Portable Electronic Device Insurance Vendor

• Definition - Title 24-A Chapter 89 - Word or Adobe PDF
• Application - Word or Adobe PDF

Preferred Provider Arrangement

• Initial Registration Form - Word or Adobe PDF
• Annual Registration Form - Word or Adobe PDF

Producer

• Definition
• Application
• Exam Information
• Resident to Nonresident Change Form - Word or Adobe PDF
• Surplus Lines
  • Application for Authority - Word or Adobe PDF
  • Notice of Reporting Requirements
  • Bond Form - Word or Adobe PDF

Reinsurance Intermediary

• Definitions - Word or Adobe PDF
• License Checklist - Word or Adobe PDF
• License Requirements - Word or Adobe PDF
• License Application - Word or Adobe PDF
• Service of Process - Word or Adobe PDF
• Statutory Contract Requirements - Word or Adobe PDF

Risk Purchasing Groups

• Registration Information - Word or Adobe PDF
• Registration Application - Word or Adobe PDF
• Service of Process - Word or Adobe PDF

Risk Retention Groups

• Registration Information - Word or Adobe PDF
• Registration Application - Word or Adobe PDF
• Registration Requirements - Word or Adobe PDF
• Service of Process - Word or Adobe PDF

Self Insurance for Workers' Compensation

• Self Insured Aggregate Benefits Paid Report Form
  • Instructions - Word or Adobe PDF
  • Online Reporting Form
• Annual Payroll Report Form
  • Instructions - Word or Adobe PDF
  • Online Reporting Form
• Initial Application for Individual Workers’ Compensation Self-Insurance Authority - Word or Adobe PDF
• Group Workers’ Compensation Self-Insurance Authority Application for Renewal - Word or Adobe PDF
• Workers’ Compensation Individual Self-Insurance Authority Renewal Application - Word or Adobe PDF
• Regulatory Funding Worksheet (RFW) for Group Self-insurers - Excel
• Surplus Distribution Worksheet (SDW) for Individual Self-insurers - Excel
• Application for Establishment of Alternative Reinsurance Account for Self-Insured Groups - Word or Adobe PDF
• Certification of Compliance with Prohibition against Political Contributions (Bulletin 320)
• Rule Chapter 250 Word
• Title 39-A M.R.S.A. Workers' Compensation

Service Contract Provider/Administrator

• Registration Information/Checklist - Word or Adobe PDF
• Registration Application - Word or Adobe PDF
• Service of Process - Word or Adobe PDF
• Title 24-A M.R.S.A. Chapter 91 Service Contracts
• Unconditional Guaranty form - Word or Adobe PDF

Special Purpose Reinsurance Vehicles

• Application - Word or Adobe PDF

Structured Settlement Transferree

• Definition
• Application - Word or Adobe PDF

Third Party Administrator

• A List of Possible Additional Licenses Required - Word or Adobe PDF
• Instructions for Requesting Confidential Treatment of Documents Filed - Adobe PDF
• Third Party Administrator (TPA) Report -- Health Claims Paid by Plan Sponsor (Note: This TPA report form is different than the annual TPA license renewal that requires a fee).
  • Instructions - Word or Adobe PDF
  • Online Reporting Form
• Title 24-A M.R.S.A. Chapter 18 "Insurance Administrators"

The following items must be submitted:

• TPA Application Checklist - Word or Adobe PDF
• A Third Party Administrator Application - with Exhibits - Word or Adobe PDF
• A "Contract Certification" - Word or Adobe PDF
• A Third Party Administrators Bond (on appropriate form) - Word or Adobe PDF
• Bond Calculation - Word or Adobe PDF

Viatical and Life Settlement Provider

• Application - Word or Adobe PDF
• Service of Process - Word or Adobe PDF

Consumer Tools

• Consumer information
• Home Inventory Tool
• Compare Individual and Small Group Health Insurance Policies
• Brochures
• File a complaint
• Glossary of terms
• Cancellation/Nonrenewal Notices
• Helpful links
• PPACA Filings/Rate increases
• Long Term Care Partnership

Industry Tools

• Physician Tiering Program Reporting
• Online Data Reporting System
• Company forms and information
• Producer and Business Entity forms and information
• Address change forms
• Fees
• Cancellation/Nonrenewal Notices
• Request for proposal
• Domestic Insurance Company Annual Statements

Employer Tools

• Workers compensation insurance
• Health insurance information
• Rural Medical Access Program

Health Care Provider Tools

• Any Willing Pharmacy Requirements

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