Forms for Insurance Licensing

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Title Description
Form ADR (11/15/2022) Adding a Designated Representative from the Business Entity’s License
Form Affiliation for DRLP Acceptable Documents for DRLP Affiliation Evidences
Form DP for PBM (11/15/2022) Designated Responsible Parties for Pharmacy Benefit Manager
Form DP for PE (11/15/2022) Designated Responsible Parties for Portable Electronics
Form DP for SCP (11/15/2022) Designated Responsible Parties for Service Contract Provider
Form DP for SSS (11/15/2022) Designated Responsible Parties for Self-Service Storage
Form DP for VPPW (11/15/2022) Designated Responsible Parties for Vehicle Protection Product Warrantor
Form for EIA Emergency Independent Adjuster form – Must be submitted by the insurers, adjusting companies, or producers after the Commissioner issues a declaration
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 LC (11/15/2022) Request for Letter of Certification / Letter of Clearance
Form List of RIs (11/15/2022) Designated Responsible Parties for Reinsurance Intermediaries
Form List of SLBs (11/15/2022) A List of licensed SLBs who is working under the business entity SLB
Form NTA (11/15/2022) Notice of Name Change – Adding/Removing Trade Name – Adding Assumed Name
Form RC (11/15/2022) Removing Classes of Insurance from a Hawaii Insurance License
Form RDR (11/15/2022) Removing a Designated Representative from the Business Entity’s License
Form VS (11/15/2022) Voluntary Surrender of License
Statement of MGA Appointment The Insurer must provide a statement of the duties the MGA will be performing on their behalf
TPA CHECKLIST (February 2021) TPA Checklist and Surety Bond
TPA ANNUAL REPORT (10/1/2019) TPA Annual Report Filing Form