Forms for Insurance Licensing

Title Description
Form AC (7/23/2018) Notice of Address Change for Hawaii Insurance Division licensees and registrants only
Form ADR (8/23/2013) Adding a Designated Representative from the Business Entity’s License
Form APPT (10/1/2019) Notice of New Appointment
Form APPTMGA (8/23/2011) Notice of New MGA Appointment
Form ARC (9/11/2017) Adding / Removing Classes of Insurance from a Hawaii Insurance License
Form BEPL (10/1/2019) Hawaii Application for Business Entity Insurance License / Registration
Form FRS (4/25/2019) Service Contract Provider’s Financial Responsibility Statement
Form FSS (4/30/2019) Vehicle Protection Product Warrantor’s Financial Security Statement
Form HPL (10/1/2019) Hawaii Application for Individual Insurance License
Form LC (6/02/2009) Request for Letter of Certification / Letter of Clearance
Form LSB LSP (10/1/2019) Hawaii Application for Individual or Legal Entity – Life Settlement Broker or Provider Insurance License
Form NTA (10/1/2019) Notice of Name Change – Adding/Removing Trade Name – Adding Assumed Name
Form PBM (6/26/2017) Pharmacy Benefit Manager Application / Renewal
Form RDR (8/23/2013) Removing a Designated Representative from the Business Entity’s License
Form SCP (7/2019) Service Contract Provider Application / Renewal
Form T (9/10/2009) Notice of Termination of Appointment
Form VPPW (7/2019) Vehicle Protection Product Warrantor Application / Renewal
Form VS (5/29/2009) Voluntary Surrender of License
TPA CHECKLIST/APPLICATION PACKET (10/1/2019) TPA Checklist & TPA Application & Surety Bond
TPA ANNUAL REPORT (10/1/2019) TPA Annual Report Filing Form