Forms for Insurance Licensing

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Title Description
Form AC (7/23/2018) Notice of Address Change for Hawaii Insurance Division licensees and registrants only
Form ADR (06/06/2022) Adding a Designated Representative from the Business Entity’s License
Form Affiliation for DRLP Acceptable Documents for DRLP Affiliation Evidences
Form APPT (10/1/2019) Notice of New Appointment
Form APPTMGA (8/23/2011) Notice of New MGA Appointment
Form ARC (3/15/2021) Adding / Removing Classes of Insurance from a Hawaii Insurance License
Form BEPL (5/31/2022) Hawaii Application for Business Entity Insurance License / Registration
Form FRS (3/1/2021) Service Contract Provider’s Financial Responsibility Statement
Form FSS (4/30/2019) Vehicle Protection Product Warrantor’s Financial Security Statement
Form HPL (5/31/2022) 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 (7/2/2021) 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 (10/6/2021) 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 CHECKLIST (February 2021) TPA Checklist and Surety Bond (for NIPR online submission only)
TPA ANNUAL REPORT (10/1/2019) TPA Annual Report Filing Form