Admissions Forms
Application for Certificate of Authority for a Multiple Employer Self-Insured Health Plan (MEWA) (MO 375-1804)
(Insurance Company Licensing FAQ)
(Certificate of Compliance with Advertising Rules)
Application for Approval to write Excess and Surplus Lines Insurance (MO 375-0474)
Application for Registration as a Risk Retention Group (MO 375-0029)
Application for Certificate of Authority (MO 375-0558)
Application to Renew Certificate of Authority (MO 375-0079)
Appointment of Director to Receive Service of Process (MO 375-0462)
Authorized Reinsurer Application and Information (MO 375-1793)
Discount Medical Plan Organization Registration Form (MO 375-0584)
Managing General Agent Contract (MO 375-0038)
MGA Appointment Form (MO 375-0019)
Managing General Agent Certification Affidavit (MO 375-0017)
Uniform Certificate of Authority Application (from the NAIC)
Bail Bond and Surety Recovery Agents Forms (FAQ)
Missouri Uniform Application for Bail Bond or Surety Recovery License (Form B1) (MO 375-0112)
Missouri Uniform Renewal Application for Bail Bond or Surety Recovery License (Form BR) (MO 375-0113)
Change of Bail Bond Status (MO 375-0031)
Change of Surety Recovery Status (MO 375-0103)
Approved Initial Basic Training Providers
Bail Bond and Surety Recovery Agent Continuing Education Forms
Bail Bond Agent, General Bail Bond Agent, and Surety Recovery Agent Affidavit of Exam Proctor (MO 375-0108)
Bail Bond Agent, General Bail Bond Agent, and Surety Recovery Agent Continuing Education Certificate of Course Completion (MO 375-0106)
Bail Bond Agent, General Bail Bond Agent, and Surety Recovery Agent Continuing Education Provider Application for Course Approval
General Bail Bond Agent Forms
General Bail Bond Agent Assignment (MO 375-0525)
General Bail Bond Agent Acknowledgement of Assignment (MO 375-0527)
General Bail Bond Affidavit (MO 375-0034)
Change of General Bail Bond Status (MO 375-0032)
Charitable Gift Annuity
Charitable Gift Annuity Notification form (MO 375-0991)
Consumer Fraud Form
Missouri Fraud Reporting Requirements and Fraud Investigation Report Form for Insurers
HMO/Managed Care Forms
Checklists
HMO Access Plan Instructions
HMO Credentialing
Life and Health Forms
Actuarial Certification -- Small Employers Health Insurance Availability Act
Affidavit for Health Benefit Plans issued to Association with Small and Large Employers (20 CSR 400 - 2.135)
Certification of Access to Providers for Treatment of Mental Health Conditions (20 CSR 400 - 2.165)
Checklists
Life Care Provider
Life Care Provider Application (MO 375-0477)
Limited Lines Self-Service Storage Insurance Producers
Limited Lines Self-Service Storage Insurance Producer Application (MO 375-1030)
Limited Lines Self-Service Storage Insurance Producer Renewal Application (MO 375-0999)
Self-Service Storage Register (MO 375-1003)
Long-term Care Partnership Forms
LTC-1 Notice to Applicant Regarding Replacement Form
LTC-2 Notice to Applicant Regarding Replacement for DR Form
LTC-3 Outline of Coverage Form
LTC-4 Long-term Care Partnership Exchange Notification Form
LTC-5 Long-term Care Partnership Program Policy Certification Form
LTC-6 Long-term Care Insurance Partnership Disclosure Notice
LTC-7 Long-term Care Insurance Partnership Delivery Notice
LTC-A Rescission Reporting Form
LTC-B Personal Worksheet Form
LTC-C Things You Should Know Before You Buy Form
LTC-D Suitability Letter Form
LTC-E Claims Denial Reporting Form
LTC-F Potential Rate Increase Form
LTC-G Replacement and Lapse Report Form
Motor Vehicle Extended Service Contract Provider and Producer Forms
Motor Vehicle Extended Service Contract Provider Registration (MO 375-0676s)
Bond of Motor Vehicle Service Contract Provider (MO 375-0595s)
Guaranty of Motor Vehicle Service Contract Obligations (MO 375-0592)
Electronic Licensing and Renewal
Electronic Name and Address Change for Business Entities and Producers - Process to be used for all individual and business entity name changes, as well as all address changes within your resident state for immediate updates.
Motor Vehicle Extended Service Contract Producer License (MO 375-0852)
Motor Vehicle Extended Service Contract Producer Renewal (MO 375-0890)
Motor Vehicle Extended Service Contract Business Entity Producer License (MO 375-0853)
Motor Vehicle Extended Service Contract Business Entity Producer License Renewal (MO 375-0912)
Change of Business Entity Producer Status (MO 375-0087)
Change of Producer Status (MO 375-0085)
Navigator Forms
Application for Navigator License (MO 375-0892)
Application for Navigator License Renewal (MO 375-0976)
Application for Navigator Entity License (MO 375-0895)
Application for Navigator Entity License Renewal (MO 375-0977)
Navigator Continuing Education Forms
Navigator Continuing Education Certification Summary
Continuing Education Certificate of Course Completion (Navigator)
Navigator Continuing Education Provider Application for Course Approval
Organizational Credit Forms
Change of Organizational Credit Business Entity Status (MO 375-0099)
Organizational Credit Business Entity Application (MO 375-0096)
Organizational Credit Renewal (MO 375-1131)
Pharmacy Benefits Manager
Pharmacy Benefits Manager Forms
Portable Electronics Insurance Forms
Portable electronics insurance application (vendor with 10 or fewer locations) (MO 375-0851)
Portable electronics insurance application (vendor with more than 10 locations) (MO 375-0868)
Producer Forms (FAQ)
Electronic Name and Address Change - Process to be used for all individual and business entity name changes, as well as all address changes within your resident state for immediate updates.
1033 Waiver Application Form
Change of Business Entity Producer Status (MO 375-0087)
Change of Producer Status (MO 375-0085)
Continuing Education Exemption Certificate – Form D (MO 375-0069)
Electronic Resident/Non-Resident Licensing and Renewal
Self-Procured Insurance Tax Report--Appendix 4 (MO 375-0498)
Non-Resident Business Entity Application
Non-Resident Producer Application
Resident Business Entity Application
Producer Continuing Education Forms
Continuing Education Certification Summary (Producer) (MO 375-0091)
Continuing Education Certificate of Course Completion (Producer) (MO 375-0092)
Property and Casualty Forms
NAIC Transmittal Document (TD-1)
Property and Casualty Rate Filings
Calculation of Loss Cost Multiplier (Exhibit B)
Expense Constant Supplement (Exhibit C)
Rate Filing Form (Exhibit A)
Public Adjuster Forms
Application/Renewal for Public Adjuster Corporation (MO 375-1119)
Application/Renewal for Public Adjuster (MO 375-0111)
Application/Renewal for Public Adjuster Solicitor (MO 375-1122)
Change of Public Adjuster Solicitor Status (375-0070)
Change of Public Adjuster Status (MO 375-0067)
Public Adjuster Bond (MO 375-0033)
Purchasing Group Forms
Application for Registration as a Purchasing Group (NAIC Form)
Reinsurance Intermediary Forms
Reinsurance Intermediary Application (MO 375-0045)
Regulation 20 CSR 700-7.100
Statute Sections 375.1110 to 375.1140, RSMo.
Service Contract Forms
Service Contract Provider Registration (MO 375-0586)
Bond of Service Contract Provider (MO 375-0594)
Guaranty of Service Contract Obligations (MO 375-0593)
Statistics Forms
All forms are available on the online portal.
Annual Statement: Page 19 Supplement to Annual Statement (MO 375-0381) (Instructions)
Annual Statement Supplement (MO 375-1802) (Instructions)
Commercial Liability Profitability Report and Commercial Liability Closed and Outstanding Claim Form (MO 375-0359) (Instructions) (Online Filing Guide)
Dram Shop Liability Insurance Premium and Loss Report (MO 375-0100) (Instructions) (Online Filing Guide)
Earthquake Insurance Survey (Items to be completed on SurveyMonkey)
Legal Malpractice Claim Report (MO 375-1662) (Online Filing Guide)
Medical Professional Liability Insurance Claim Report (MO 375-0304) (Instructions) (Online Filing Guide)
Medical Professional Liability Severity Codes
Medicare Supplement Insurance Experience Report (MO 375-0307) (Online Filing Guide)
Mortgage Guaranty (Online Filing Guide)
Products Liability Closed Claim Report (MO 375-1663) (Online Filing Guide)
Products Liability Summary Report Form
Real Estate Malpractice Claim Report (MO 375-1661) (Online Filing Guide)
Surplus Lines
Application for Surplus Lines (MO 375-1120)
Electronic Name and Address Change - Process to be used for all individual and business entity name changes, as well as all address changes within your resident state for immediate updates.
Tax Forms (FAQ)
Insurance Producers Report (MO 375-0110)
Quarterly Administrative Surcharge Report Form (MO 375-0701)
Casualty Insurance Companies (MO 375-0409)
Chapter 380 Missouri Mutual Companies (MO 375-0429)
Life Insurance Companies (MO 375-0411)
Prior Year Tax Information
Third Party Administrator Forms
TPA Checklist
TPA Web Portal User Guide
Administrator Application (MO 375-1685)
TPA 376.1092 form (MO 376-1092)
Bond of Third Party Administrator (MO 375-1811)
Notification of Insurer/Trust Agreement (MO 375-1684)
TPA Questionnaire (MO 375-0083)
Title Forms
Title Insurance Producer/Business Entity Producer Forms
T-1 Title Insurance Premium and Title Service Charge Disclosure Statement
T-2 Notice of Availability of Owner's Title Insurance
T-3 Notice of Closing or Settlement Risk
T-4 Affiliated Business Disclosure
T-5A Agency Financial Interest Report
T-5B Affiliated Business Arrangement Report
Contact Information
consumeraffairs@insurance.mo.gov 573-751-1922
Title Insurance Companies Forms
T-5B Affiliated Business Arrangement Report
T-6A Missouri Title Insurer's Statutory Onsite Review Report
T-6B Missouri Title Insurer's Onsite Review Sampling Methods
T-7 Uniform Premium (Risk Rate) Report
T-8 Seller's Closing Protection Letter
T-8 Seller's Closing Protection Letter
T-9 Lender's Closing Protection Letter
T-9 Lender's Closing Protection Letter
T-12 Annual Title Plant Registration
Title Premium Reserve Worksheet
Contact Information
Title.forms@insurance.mo.gov 573-751-7470
Title Premium Reserve Worksheet Questions
insurancesolvency@insurance.mo.gov 573-526-4877
Utilization Review Agents
Certificate of Registration Application for Utilization Review Agents (MO 375-0049)
Vehicle Protection Product Forms
Vehicle Protection Product Registration (MO 375-0686)
Workers' Compensation Forms
Self-Insured Workers' Compensation Filing User Guide
Individual Self-Insured Employer Form and Instructions
2023 Individual Self-Insured Tax Return (Table 1)
2023 Individual Self-Insured Table 1 Instructions
287.280 Group Self-Insured Employers Forms and Instructions
287.280 Group Self-Insured Tax Return Table 1 Workpaper
Group Form
287.280 Group Self-Insured Instructions
537.620 Group Self-Insured Employers Forms and Instructions
537.620 Group Self-Insured Tax Return Table 1 Workpaper
Group Form
537.620 Group Self-Insured Instructions
What is Individual Self-Insurance?
Self-Insured Workers' Compensation (FAQ)
What is Group Trust Self-Insurance?
Group and Trust Self-Insured Workers' Compensation (FAQ)
Independent Rate Filing Form (Exhibit A)
Limited Liability Company Exclusion Endorsem*nts
Rate Development Summary Form (Exhibit B)
