Florida Regulations 69O-136.100: Forms Incorporated by Reference
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(1) The forms in subsection (2) of this rule are available and may be printed from the Office of Insurance Regulation’s website: https://www.floir.com/iportal, and are hereby incorporated by reference.
(2)(a) Form OIR-B1-PCR3, “”Filing requirements Advisory Organization,”” effective 7/23, hereby incorporated by reference and available at http://www.flrules.org/Gateway/reference.asp?No=Ref-16192, electronically at https://www.floir.com/iportal.
(b) Form OIR-B2-1093, “”Small Employer Carrier’s Application to Become a Risk Assuming Carrier or a Reinsuring Carrier, as Required by Section 627.6699(9), Florida Statutes,”” effective 7/23, available at http://www.flrules.org/Gateway/reference.asp?No=Ref-16193.
(c) Forms OIR-C1
1. Form OIR-C1-0500, “”UCAA Biographical Affidavit Addendum Blank,”” effective 7/23, available at http://www.flrules.org/Gateway/reference.asp?No=Ref-16194;
2. Form OIR-C1-0501, “”UCAA Biographical Affidavit Addendum Education,”” effective 7/23, available at http://www.flrules.org/Gateway/reference.asp?No=Ref-16195;
3. Form OIR-C1-0502, “”UCAA Biographical Affidavit Addendum Employment,”” effective 7/23, available at http://www.flrules.org/Gateway/reference.asp?No=Ref-16196;
4. Form OIR-C1-0503, “”UCAA Biographical Affidavit Addendum General,”” effective 7/23, available at http://www.flrules.org/Gateway/reference.asp?No=Ref-16197;
5. Form OIR-C1-0504, “”UCAA Biographical Affidavit Addendum Licenses,”” effective 7/23, available at http://www.flrules.org/Gateway/reference.asp?No=Ref-16198;
6. Form OIR-C1-0505, “”UCAA Biographical Affidavit Addendum Professional,”” effective 7/23, available at http://www.flrules.org/Gateway/reference.asp?No=Ref-16199;
7. Form OIR-C1-0506, “”UCAA Biographical Affidavit Addendum Residence,”” effective 7/23, available at http://www.flrules.org/Gateway/reference.asp?No=Ref-16200;
8. Form OIR-C1-0507, “”UCAA Biographical Affidavit Addendum Societies,”” effective 7/23, available at http://www.flrules.org/Gateway/reference.asp?No=Ref-16201;
9. Form OIR-C1-0508, “”Uniform Certificate of Authority Application (UCAA) Affidavit of Lost Certificate of Authority,”” effective 7/23, available at http://www.flrules.org/Gateway/reference.asp?No=Ref-16202;
10. Form OIR-C1-0509, “”Uniform Certificate of Authority Application (UCAA) Biographical Affidavit Cover Letter Holding Company Structure,”” effective 7/23, available at http://www.flrules.org/Gateway/reference.asp?No=Ref-16203;
11. Form OIR-C1-0510, “”Uniform Certificate of Authority Application (UCAA) Corporate Amendments Application Application to Amend Certificate of Authority,”” effective 7/23, available at http://www.flrules.org/Gateway/reference.asp?No=Ref-16206;
12. Form OIR-C1-0511, “”Uniform Certificate of Authority Application (UCAA) Corporate Amendments Application Checklist for Corporate Amendments Application Only,”” effective 7/23, available at http://www.flrules.org/Gateway/reference.asp?No=Ref-16208;
13. Form OIR-C1-0512, “”Uniform Certificate of Authority Application Questionnaire for Adding or Deleting Lines of Business to an Existing Certificate of Authority,”” effective 7/23, available at http://www.flrules.org/Gateway/reference.asp?No=Ref-16210;
14. Form OIR-C1-0520, “”Uniform Certificate of Authority Application (UCAA) Primary Application Checklist for Primary Application Only”” effective 7/23, available at http://www.flrules.org/Gateway/reference.asp?No=Ref-16212;
15. Form OIR-C1-0521, “”Uniform Certificate of Authority Application (UCAA) Primary Application”” effective 7/23, available at http://www.flrules.org/Gateway/reference.asp?No=Ref-16213;
16. Form OIR-C1-0522, “”Uniform Certificate of Application (UCAA) Change of Mailing Address/Contact Notification Form,”” effective 7/23, http://www.flrules.org/Gateway/reference.asp?No=Ref-16214;
17. Form OIR-C1-144, “”Service of Process Consent & Agreement,”” effective 6/04, available at http://www.flrules.org/Gateway/reference.asp?No=Ref-14435;
18. Form OIR-C1-448, “”Application for Acquisition of Controlling Stock, Ownership Interest, Assets, or Control of a Florida Specialty Insurer; Merger or Consolidation,”” effective 7/21, available at http://www.flrules.org/Gateway/reference.asp?No=Ref-14436;
19. Form OIR-C1-513, “”Application for Registration as a Risk Retention Group,”” effective 7/23, available at http://www.flrules.org/Gateway/reference.asp?No=Ref-16216;
20. Form OIR-C1-515, “”Application for Registration as a Risk Purchasing Group,”” effective 7/23, available at http://www.flrules.org/Gateway/reference.asp?No=Ref-16217;
21. Form OIR-C1-845, “”Application for Certificate of Authority Commercial Self-Insurance Fund,”” effective 7/23, available at http://www.flrules.org/Gateway/reference.asp?No=Ref-16227;
22. Form OIR-C1-905, “”Instructions for Furnishing Background Investigative Reports,”” effective 6/20, hereby incorporated by reference and available at http://www.flrules.org/Gateway/reference.asp?No=Ref-14437;
23. Form OIR-C1-908, “”Application for Permit Domestic Reciprocal Insurer,”” effective 7/23, available at http://www.flrules.org/Gateway/reference.asp?No=Ref-16228;
24. Form OIR-C1-916, “”Application for Eligibility as a Surplus Lines Insurer,”” effective 7/23, available at www. http://www.flrules.org/Gateway/reference.asp?No=Ref-16229;
25. Form OIR-C1-918, “”Application for Acquisition of Controlling Stock of a Florida Domestic Insurer,”” effective 7/21, available at https://www.flrules.org/Gateway/reference.asp?No=Ref-14438;
26. Form OIR-C1-938, “”Fingerprint Payment and Submission Procedure,”” effective 6/20, hereby incorporated by reference and available at https://www.flrules.org/Gateway/reference.asp?No=Ref-14439;
27. Form OIR-C1-1413, “”Uniform Certificate of Authority Application (UCAA) Expansion Application,”” effective 7/23, available at http://www.flrules.org/Gateway/reference.asp?No=Ref-16230;
28. Form OIR-C1-1414, “”Uniform Certificate of Authority Application (UCAA) Expansion Application Checklist For Expansion Application Only,”” effective 7/23, available at http://www.flrules.org/Gateway/reference.asp?No=Ref-16231;
29. Form OIR-C1-1416, “”Uniform Certificate of Authority Application (UCAA) Lines of Insurance,”” effective 1/20, available at http://www.flrules.org/Gateway/reference.asp?No=Ref-16232;
30. Form OIR-C1-1422, “”Uniform Certificate of Authority Application Questionnaire,”” effective 7/23, available at http://www.flrules.org/Gateway/reference.asp?No=Ref-16233;
31. Form OIR-C1-1423, “”Uniform Certificate of Authority Application (UCAA) Biographical Affidavit,”” effective 12/20, hereby incorporated by reference and available at https://www.flrules.org/Gateway/reference.asp?No=Ref-14441
32. Form OIR-C1-1424, “”Uniform Certificate of Authority Application,”” effective 7/23, available at http://www.flrules.org/Gateway/reference.asp?No=Ref-16234;
33. Form OIR-C1-1467, “”Disclaimer of Control – Individual,”” effective 7/21, available at http://www.flrules.org/Gateway/reference.asp?No=Ref-14442
34. Form OIR-C1-1468, “”Disclaimer of Control – Entity,”” effective 7/21, available at https://www.flrules.org/Gateway/reference.asp?No=Ref-14443;
35. Form OIR-C1-1522, “”Primary Application Florida Specific Information,”” effective 7/23, available at http://www.flrules.org/Gateway/reference.asp?No=Ref-16235;
36. Form OIR-C1-1524, “”Uniform Certificate of Authority Application (UCAA) Uniform Consent to Service of Process,”” effective 12/19, available at https://www.flrules.org/Gateway/reference.asp?No=Ref-14444;
37. Form OIR-C1-1654, “”Determination of Eligibility to Operate as an Alien Insurer in Florida Pursuant to Section 624.402(9), Florida Statutes,”” effective 7/23, available at http://www.flrules.org/Gateway/reference.asp?No=Ref-16236;
38. Form OIR-C1-2069, “”Letter of Notification,”” effective 7/23, available at http://www.flrules.org/Gateway/reference.asp?No=Ref-16237;
39. Form OIR-C1-2176, “”Letter of Notification/Registration to Operate as a Non-US Based (Alien) Insurer (also referred to as “”Offshore Insurer””) in Florida Pursuant to Section 624.402(8), Florida Statutes,”” effective 7/23, available at http://www.flrules.org/Gateway/reference.asp?No=Ref-16238;
40. Form OIR-C1-2211, “”Disclaimer of Control – Investment Companies,”” effective 7/21, available at https://www.flrules.org/Gateway/reference.asp?No=Ref-14445;
41. Form OIR-C1-2221, “”Management Information Form,”” effective 6/20, available at https://www.flrules.org/Gateway/reference.asp?No=Ref-14446;
42. Form OIR-C1-PCR1, “”Application for License Rating Organization,”” effective 7/23, hereby incorporated by reference and available at http://www.flrules.org/Gateway/reference.asp?No=Ref-16239; and
43. Form OIR-C1-PCR2, “”License Renewal Rating Organization,”” effective 7/23, hereby incorporated by reference and available at http://www.flrules.org/Gateway/reference.asp?No=Ref-16239, filed electronically at https://www.floir.com/iportal.
(d) Forms OIR-D0
1. Form OIR-D0-896, “”UCAA Proforma Financial Statements, Property and Casualty Insurance Company,”” effective 1/19, available at https://www.flrules.org/Gateway/reference.asp?No=Ref-14448;
2. Form OIR-D0-904, “”UCAA Proforma Financial Statements, Life & Health Insurer,”” effective 1/19, available at www.flrules.org/14449;
3. Form OIR-D0-2119, “”UCAA Proforma Financial Statements, Title Insurance Company,”” effective 1/19, available at https://www.flrules.org/Gateway/reference.asp?No=Ref-14593; and
4. Form OIR-D0-2165, “”UCAA Proforma Financial Statements, Health,”” effective 1/19, available at https://www.flrules.org/Gateway/reference.asp?No=Ref-14450.
Rulemaking Authority 624.308(1), 624.413(1), 628.461(13), 628.4615(15), 628.535 FS. Law Implemented 624.307(1), 624.34, 624.404, 624.413, 624.424(6), 624.501, 624.5091, 626.9928, 628.451, 628.461, 628.4615, 628.471, 628.801, 634.252, 634.3073, 634.4085, 636.065, 641.255, 641.416, 642.032, 651.024, 651.0245 FS. History-New 7-21-22, Amended 1-7-24.
Terms Used In Florida Regulations 69O-136.100
- Affidavit: A written statement of facts confirmed by the oath of the party making it, before a notary or officer having authority to administer oaths.
- Assets: (1) The property comprising the estate of a deceased person, or (2) the property in a trust account.
(b) Form OIR-B2-1093, “”Small Employer Carrier’s Application to Become a Risk Assuming Carrier or a Reinsuring Carrier, as Required by Section 627.6699(9), Florida Statutes,”” effective 7/23, available at http://www.flrules.org/Gateway/reference.asp?No=Ref-16193.
(c) Forms OIR-C1
1. Form OIR-C1-0500, “”UCAA Biographical Affidavit Addendum Blank,”” effective 7/23, available at http://www.flrules.org/Gateway/reference.asp?No=Ref-16194;
2. Form OIR-C1-0501, “”UCAA Biographical Affidavit Addendum Education,”” effective 7/23, available at http://www.flrules.org/Gateway/reference.asp?No=Ref-16195;
3. Form OIR-C1-0502, “”UCAA Biographical Affidavit Addendum Employment,”” effective 7/23, available at http://www.flrules.org/Gateway/reference.asp?No=Ref-16196;
4. Form OIR-C1-0503, “”UCAA Biographical Affidavit Addendum General,”” effective 7/23, available at http://www.flrules.org/Gateway/reference.asp?No=Ref-16197;
5. Form OIR-C1-0504, “”UCAA Biographical Affidavit Addendum Licenses,”” effective 7/23, available at http://www.flrules.org/Gateway/reference.asp?No=Ref-16198;
6. Form OIR-C1-0505, “”UCAA Biographical Affidavit Addendum Professional,”” effective 7/23, available at http://www.flrules.org/Gateway/reference.asp?No=Ref-16199;
7. Form OIR-C1-0506, “”UCAA Biographical Affidavit Addendum Residence,”” effective 7/23, available at http://www.flrules.org/Gateway/reference.asp?No=Ref-16200;
8. Form OIR-C1-0507, “”UCAA Biographical Affidavit Addendum Societies,”” effective 7/23, available at http://www.flrules.org/Gateway/reference.asp?No=Ref-16201;
9. Form OIR-C1-0508, “”Uniform Certificate of Authority Application (UCAA) Affidavit of Lost Certificate of Authority,”” effective 7/23, available at http://www.flrules.org/Gateway/reference.asp?No=Ref-16202;
10. Form OIR-C1-0509, “”Uniform Certificate of Authority Application (UCAA) Biographical Affidavit Cover Letter Holding Company Structure,”” effective 7/23, available at http://www.flrules.org/Gateway/reference.asp?No=Ref-16203;
11. Form OIR-C1-0510, “”Uniform Certificate of Authority Application (UCAA) Corporate Amendments Application Application to Amend Certificate of Authority,”” effective 7/23, available at http://www.flrules.org/Gateway/reference.asp?No=Ref-16206;
12. Form OIR-C1-0511, “”Uniform Certificate of Authority Application (UCAA) Corporate Amendments Application Checklist for Corporate Amendments Application Only,”” effective 7/23, available at http://www.flrules.org/Gateway/reference.asp?No=Ref-16208;
13. Form OIR-C1-0512, “”Uniform Certificate of Authority Application Questionnaire for Adding or Deleting Lines of Business to an Existing Certificate of Authority,”” effective 7/23, available at http://www.flrules.org/Gateway/reference.asp?No=Ref-16210;
14. Form OIR-C1-0520, “”Uniform Certificate of Authority Application (UCAA) Primary Application Checklist for Primary Application Only”” effective 7/23, available at http://www.flrules.org/Gateway/reference.asp?No=Ref-16212;
15. Form OIR-C1-0521, “”Uniform Certificate of Authority Application (UCAA) Primary Application”” effective 7/23, available at http://www.flrules.org/Gateway/reference.asp?No=Ref-16213;
16. Form OIR-C1-0522, “”Uniform Certificate of Application (UCAA) Change of Mailing Address/Contact Notification Form,”” effective 7/23, http://www.flrules.org/Gateway/reference.asp?No=Ref-16214;
17. Form OIR-C1-144, “”Service of Process Consent & Agreement,”” effective 6/04, available at http://www.flrules.org/Gateway/reference.asp?No=Ref-14435;
18. Form OIR-C1-448, “”Application for Acquisition of Controlling Stock, Ownership Interest, Assets, or Control of a Florida Specialty Insurer; Merger or Consolidation,”” effective 7/21, available at http://www.flrules.org/Gateway/reference.asp?No=Ref-14436;
19. Form OIR-C1-513, “”Application for Registration as a Risk Retention Group,”” effective 7/23, available at http://www.flrules.org/Gateway/reference.asp?No=Ref-16216;
20. Form OIR-C1-515, “”Application for Registration as a Risk Purchasing Group,”” effective 7/23, available at http://www.flrules.org/Gateway/reference.asp?No=Ref-16217;
21. Form OIR-C1-845, “”Application for Certificate of Authority Commercial Self-Insurance Fund,”” effective 7/23, available at http://www.flrules.org/Gateway/reference.asp?No=Ref-16227;
22. Form OIR-C1-905, “”Instructions for Furnishing Background Investigative Reports,”” effective 6/20, hereby incorporated by reference and available at http://www.flrules.org/Gateway/reference.asp?No=Ref-14437;
23. Form OIR-C1-908, “”Application for Permit Domestic Reciprocal Insurer,”” effective 7/23, available at http://www.flrules.org/Gateway/reference.asp?No=Ref-16228;
24. Form OIR-C1-916, “”Application for Eligibility as a Surplus Lines Insurer,”” effective 7/23, available at www. http://www.flrules.org/Gateway/reference.asp?No=Ref-16229;
25. Form OIR-C1-918, “”Application for Acquisition of Controlling Stock of a Florida Domestic Insurer,”” effective 7/21, available at https://www.flrules.org/Gateway/reference.asp?No=Ref-14438;
26. Form OIR-C1-938, “”Fingerprint Payment and Submission Procedure,”” effective 6/20, hereby incorporated by reference and available at https://www.flrules.org/Gateway/reference.asp?No=Ref-14439;
27. Form OIR-C1-1413, “”Uniform Certificate of Authority Application (UCAA) Expansion Application,”” effective 7/23, available at http://www.flrules.org/Gateway/reference.asp?No=Ref-16230;
28. Form OIR-C1-1414, “”Uniform Certificate of Authority Application (UCAA) Expansion Application Checklist For Expansion Application Only,”” effective 7/23, available at http://www.flrules.org/Gateway/reference.asp?No=Ref-16231;
29. Form OIR-C1-1416, “”Uniform Certificate of Authority Application (UCAA) Lines of Insurance,”” effective 1/20, available at http://www.flrules.org/Gateway/reference.asp?No=Ref-16232;
30. Form OIR-C1-1422, “”Uniform Certificate of Authority Application Questionnaire,”” effective 7/23, available at http://www.flrules.org/Gateway/reference.asp?No=Ref-16233;
31. Form OIR-C1-1423, “”Uniform Certificate of Authority Application (UCAA) Biographical Affidavit,”” effective 12/20, hereby incorporated by reference and available at https://www.flrules.org/Gateway/reference.asp?No=Ref-14441
32. Form OIR-C1-1424, “”Uniform Certificate of Authority Application,”” effective 7/23, available at http://www.flrules.org/Gateway/reference.asp?No=Ref-16234;
33. Form OIR-C1-1467, “”Disclaimer of Control – Individual,”” effective 7/21, available at http://www.flrules.org/Gateway/reference.asp?No=Ref-14442
34. Form OIR-C1-1468, “”Disclaimer of Control – Entity,”” effective 7/21, available at https://www.flrules.org/Gateway/reference.asp?No=Ref-14443;
35. Form OIR-C1-1522, “”Primary Application Florida Specific Information,”” effective 7/23, available at http://www.flrules.org/Gateway/reference.asp?No=Ref-16235;
36. Form OIR-C1-1524, “”Uniform Certificate of Authority Application (UCAA) Uniform Consent to Service of Process,”” effective 12/19, available at https://www.flrules.org/Gateway/reference.asp?No=Ref-14444;
37. Form OIR-C1-1654, “”Determination of Eligibility to Operate as an Alien Insurer in Florida Pursuant to Section 624.402(9), Florida Statutes,”” effective 7/23, available at http://www.flrules.org/Gateway/reference.asp?No=Ref-16236;
38. Form OIR-C1-2069, “”Letter of Notification,”” effective 7/23, available at http://www.flrules.org/Gateway/reference.asp?No=Ref-16237;
39. Form OIR-C1-2176, “”Letter of Notification/Registration to Operate as a Non-US Based (Alien) Insurer (also referred to as “”Offshore Insurer””) in Florida Pursuant to Section 624.402(8), Florida Statutes,”” effective 7/23, available at http://www.flrules.org/Gateway/reference.asp?No=Ref-16238;
40. Form OIR-C1-2211, “”Disclaimer of Control – Investment Companies,”” effective 7/21, available at https://www.flrules.org/Gateway/reference.asp?No=Ref-14445;
41. Form OIR-C1-2221, “”Management Information Form,”” effective 6/20, available at https://www.flrules.org/Gateway/reference.asp?No=Ref-14446;
42. Form OIR-C1-PCR1, “”Application for License Rating Organization,”” effective 7/23, hereby incorporated by reference and available at http://www.flrules.org/Gateway/reference.asp?No=Ref-16239; and
43. Form OIR-C1-PCR2, “”License Renewal Rating Organization,”” effective 7/23, hereby incorporated by reference and available at http://www.flrules.org/Gateway/reference.asp?No=Ref-16239, filed electronically at https://www.floir.com/iportal.
(d) Forms OIR-D0
1. Form OIR-D0-896, “”UCAA Proforma Financial Statements, Property and Casualty Insurance Company,”” effective 1/19, available at https://www.flrules.org/Gateway/reference.asp?No=Ref-14448;
2. Form OIR-D0-904, “”UCAA Proforma Financial Statements, Life & Health Insurer,”” effective 1/19, available at www.flrules.org/14449;
3. Form OIR-D0-2119, “”UCAA Proforma Financial Statements, Title Insurance Company,”” effective 1/19, available at https://www.flrules.org/Gateway/reference.asp?No=Ref-14593; and
4. Form OIR-D0-2165, “”UCAA Proforma Financial Statements, Health,”” effective 1/19, available at https://www.flrules.org/Gateway/reference.asp?No=Ref-14450.
Rulemaking Authority 624.308(1), 624.413(1), 628.461(13), 628.4615(15), 628.535 FS. Law Implemented 624.307(1), 624.34, 624.404, 624.413, 624.424(6), 624.501, 624.5091, 626.9928, 628.451, 628.461, 628.4615, 628.471, 628.801, 634.252, 634.3073, 634.4085, 636.065, 641.255, 641.416, 642.032, 651.024, 651.0245 FS. History-New 7-21-22, Amended 1-7-24.