Fla. Admin. Code Ann. R. 69O-136.100 - [Effective 3/31/2025] Forms Incorporated by Reference

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(1) The forms incorporated in 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) Forms OIR-A3

1. Form OIR-A3-110, "License Continuance Form Service Warranty Association," effective 01/25, hereby incorporated by reference and available at https://www.flrules.org/Gateway/reference.asp?No=Ref-17411;

2. Form OIR-A3-453, "Premium Finance Company Surety Bond," effective 01/25, hereby incorporated by reference and available at https://www.flrules.org/Gateway/reference.asp?No=Ref-17413;

3. Form OIR-A3-455, "Home or Service Warranty Association Surety Bond," effective 01/25, hereby incorporated by reference and available at https://www.flrules.org/Gateway/reference.asp?No=Ref-17414;

4. Form OIR-A3-467 LR, "Application for License Continuance Motor Vehicle Service Agreement Company," effective 01/25, hereby incorporated by reference and available at https://www.flrules.org/Gateway/reference.asp?No=Ref-17415;

5. Form OIR-A3-478, "Legal Expense Insurance Corporation Surety Bond," effective 01/25, available at https://www.flrules.org/Gateway/reference.asp?No=Ref-17416;

6. Form OIR-A3-955, "License Continuance Form Service Warranty Association Manufacturer or Affiliate," effective 01/25, hereby incorporated by reference and available at https://www.flrules.org/Gateway/reference.asp?No=Ref-17417;

7. Form OIR-A3-1073, "Application for Renewal of License Home Warranty Association," effective 01/25, hereby incorporated by reference and available at https://www.flrules.org/Gateway/reference.asp?No=Ref-17418;

8. Form OIR-A3-1077, "Application for License Continuance Legal Expense Insurance," effective 01/25, hereby incorporated by reference and available at https://www.flrules.org/Gateway/reference.asp?No=Ref-17419; and

9. Form OIR-A3-1563, "Application for Renewal of License Premium Finance Company," effective 01/25, hereby incorporated by reference and available at https://www.flrules.org/Gateway/reference.asp?No=Ref-17420.

(b) 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.

(c) 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.

(d) Forms OIR-C1

1. 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;

2. 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;

3. 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;

4. 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;

5. 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;

6. Form OIR-C1-100, "Application for Permit Domestic Stock or Mutual Insurer", effective 1/25, available at https://flrules.org/Gateway/reference.asp?No=Ref-17909.

7. Form OIR-C1-101, "Application to Redomesticate a Stock or Mutual Insurer", effective 1/25, available at https://flrules.org/Gateway/reference.asp?No=Ref-17910.

8. Form OIR-C1-144, "Service of Process Consent & Agreement," effective 01/25, available at http://www.flrules.org/Gateway/reference.asp?No=Ref-17423;

9. Form OIR-C1-150, "Application for Acquisition of the Attorney-in-Fact of a Domestic Reciprocal Insurer," effective 01/25, https://www.flrules.org/Gateway/reference.asp?No=Ref-17424;

10. Form OIR-C1-151, "Application for Certificate of Authority Domestic Reciprocal Insurer," effective 01/25, available at https://www.flrules.org/Gateway/reference.asp?No=Ref-17425;

11. Form OIR-C1-152, "Letter of Notification Acquisition of the Attorney-in-Fact of a Domestic Reciprocal Insurer," effective 01/25, available at https://www.flrules.org/Gateway/reference.asp?No=Ref-17426;

12. Form OIR-C1-153, "Application for Merger or Conversion Reciprocal Insurer," effective 01/25, hereby incorporated by reference and available at https://www.flrules.org/Gateway/reference.asp?No=Ref-17427;

13. Form OIR-C1-448, "Application for Acquisition of Controlling Stock, Ownership Interest, Assets, or Control of a Florida Specialty Insurer; Merger or Consolidation," effective 01/25, available at http://www.flrules.org/Gateway/reference.asp?No=Ref-17428;

14. Form OIR-C1-454, "Personal Financial Statement," effective 01/25, hereby incorporated by reference and available at https://www.flrules.org/Gateway/reference.asp?No=Ref-17430;

15. Form OIR-C1-471, "Application for Provisional Certificate of Authority for a Continuing Care Provider," effective 01/25, hereby incorporated by reference and available at https://www.flrules.org/Gateway/reference.asp?No=Ref-17431;

16. Form OIR-C1-473, "Application for Certificate of Authority for a Continuing Care Provider," effective 01/25, hereby incorporated by reference and available at https://www.flrules.org/Gateway/reference.asp?No=Ref-17432;

17. Form OIR-C1-480, "Application for Certificate of Authority Legal Expense Insurance," effective 01/25, available at https://www.flrules.org/Gateway/reference.asp?No=Ref-17433;

18. Form OIR-C1-483, "Application for Certificate of Authority Prepaid Health Clinic," effective 01/25, hereby incorporated by reference and available at https://www.flrules.org/Gateway/reference.asp?No=Ref-17434;

19. Form OIR-C1-490, "Application for License Home Warranty Association," effective 01/25, hereby incorporated by reference and available at https://flrules.org/Gateway/reference.asp?No=Ref-17911;

20. Form OIR-C1-513, "Application for Registration as a Risk Retention Group," effective 01/25, available at http://www.flrules.org/Gateway/reference.asp?No=Ref-17437;

21. Form OIR-C1-515, "Application for Registration as a Risk Purchasing Group," effective 01/25, available at http://www.flrules.org/Gateway/reference.asp?No=Ref-17912;

22. Form OIR-C1-845, "Application for Certificate of Authority Commercial Self-Insurance Fund," effective 01/25, available at http://www.flrules.org/Gateway/reference.asp?No=Ref-17913;

23. Form OIR-C1-908, "Application for Permit Domestic Reciprocal Insurer," effective 01/25, available at http://www.flrules.org/Gateway/reference.asp?No=Ref-17914;

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 01/25, available at https://www.flrules.org/Gateway/reference.asp?No=Ref-17442;

26. Form OIR-C1-942, "Application for Certificate of Authority Health Maintenance Organization," effective 01/25, hereby incorporated by reference and available at https://www.flrules.org/Gateway/reference.asp?No=Ref-17443;

27. Form OIR-C1-957, "Instructions for Statutory Compliance of Forms: Premium Finance Companies," effective 01/25, hereby incorporated by reference and available at https://www.flrules.org/Gateway/reference.asp?No=Ref-17915;

28. Form OIR-C1-958, "Application for License Premium Finance Company," effective 01/25, hereby incorporated by reference and available at https://www.flrules.org/Gateway/reference.asp?No=Ref-17445;

29. Form OIR-C1-983, "Application for Certificate of Authority Multiple Employer Welfare Arrangement," effective 01/25, hereby incorporated by reference and available at https://www.flrules.org/Gateway/reference.asp?No=Ref-17446;

30. Form OIR-C1-989, "Application for License Service Warranty Association Manufacturer or Affiliate," effective 01/25, hereby incorporated by reference and available at https://www.flrules.org/Gateway/reference.asp?No=Ref-17447;

31. Form OIR-C1-994, "Application for License Motor Vehicle Service Agreement Company," effective 01/25, hereby incorporated by reference and available at https://www.flrules.org/Gateway/reference.asp?No=Ref-17448;

32. Form OIR-C1-997, "Application for License Service Warranty Association," effective 01/25, hereby incorporated by reference and available at https://www.flrules.org/Gateway/reference.asp?No=Ref-17449;

33. Form OIR-C1-1075, "Application for Certificate of Authority of an Insurance Administrator," effective 01/25, hereby incorporated by reference and available at https://www.flrules.org/Gateway/reference.asp?No=Ref-17450;

34. Form OIR-C1-1119, "Application for Certificate of Authority Prepaid Limited Health Service Organization," effective 01/25, hereby incorporated by reference and available at https://www.flrules.org/Gateway/reference.asp?No=Ref-17451;

35. Form OIR-C1-1208, "Notification to the Office of Insurance Regulation as a Qualifying Issuer of Donor Annuity Agreements Pursuant to section 627.481, F.S.," effective 01/25, is hereby incorporated by reference and available at https://www.flrules.org/Gateway/reference.asp?No=Ref-17452.

36. 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;

37. 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;

38. Form OIR-C1-1416, "Uniform Certificate of Authority Application (UCAA) Lines of Insurance," effective 07/23, available at http://www.flrules.org/Gateway/reference.asp?No=Ref-16232;

39. 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;

40. Form OIR-C1-1424, "Uniform Certificate of Authority Application," effective 7/23, available at http://www.flrules.org/Gateway/reference.asp?No=Ref-16234;

41. Form OIR-C1-1467, "Disclaimer of Control - Individual," effective 7/21, available at http://www.flrules.org/Gateway/reference.asp?No=Ref-14442

42. Form OIR-C1-1468, "Disclaimer of Control - Entity," effective 7/21, available at https://www.flrules.org/Gateway/reference.asp?No=Ref-14443;

43. Form OIR-C1-1522, "Primary Application Florida Specific Information," effective 7/23, available at http://www.flrules.org/Gateway/reference.asp?No=Ref-16235;

44. 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;

45. Form OIR-C1-1606, "Application for License Discount Plan Organization (DPO)," effective 01/25, hereby incorporated by reference and available at https://www.flrules.org/Gateway/reference.asp?No=Ref-17453;

46. 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;

47. Form OIR-C1-2069, "Letter of Notification," effective 01/25, available at http://www.flrules.org/Gateway/reference.asp?No=Ref-17454;

48. 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;

49. Form OIR-C1-2211, "Disclaimer of Control - Investment Companies," effective 7/21, available at https://www.flrules.org/Gateway/reference.asp?No=Ref-14445;

50. Form OIR-C1-2218, "Application for Expansion of a Certificated Continuing Care Facility," effective 01/25, hereby incorporated by reference and available at https://www.flrules.org/Gateway/reference.asp?No=Ref-17455;

51. Form OIR-C1-2219, "Application for the Simultaneous Acquisition of a Continuing Care Facility and Issuance of a Certificate of Authority to a Provider," effective 01/25, hereby incorporated by reference and available at https://www.flrules.org/Gateway/reference.asp?No=Ref-17916;

52. Form OIR-C1-2220, "Consolidated Application for Provisional Certificate of Authority and Certificate of Authority for a Continuing Care Provider," effective 01/25, hereby incorporated by reference and available at https://www.flrules.org/Gateway/reference.asp?No=Ref-17457;

53. Form OIR-C1-2221, "Management Information Form," effective 01/25, available at https://www.flrules.org/Gateway/reference.asp?No=Ref-17917;

54. 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

55. Form OIR-C1-PCR2, "License Renewal Rating Organization," effective 01/25, hereby incorporated by reference and available at http://www.flrules.org/Gateway/reference.asp?No=Ref-17459, filed electronically at https://www.floir.com/iportal.

(e) 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 https://www.flrules.org/Gateway/reference.asp?No=Ref-16761;

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.

(3) The "biographical information package" is defined as all of the forms listed in this subsection.

(a) All individuals submitting a biographical information package shall complete and submit forms:

1. Form OIR-C1-938, "Fingerprints and Social Security Number," effective 01/25, hereby incorporated by reference and available at https://www.flrules.org/Gateway/reference.asp?No=Ref-17461; and

2. 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;

(b) In addition, the individual shall submit all of the following forms that are applicable to their circumstances:

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; and,

9. 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.

Notes

Fla. Admin. Code Ann. R. 69O-136.100

Rulemaking Authority 624.308(1), 624.413(1), 624.439, 624.4431, 624.490, 626.8805(2), 626.8991, 627.481(11), 627.6699, 627.828(2), 628.461(13), 628.4615(15), 628.535, 629.091(2), 629.225(1)(a)1., (11), 629.227(1), 629.291(2), 629.525, 634.021, 634.061(1), (2)(c), 634.302, 634.402, 636.067, 636.232, 641.36, 641.403, 641.405(2), 642.021(2), 651.015(3), 651.0215(2), 651.022(2), 651.0245(3), (5), (6), 651.0246(1) FS. Law Implemented 624.307(1), 624.321, 624.34, 624.401, 624.404, 624.407, 624.413, 624.422, 624.424, 624.438, 624.439, 624.490, 624.501, 624.5091, 626.8805, 627.6699, 626.9928, 627.481, 627.828, 627.829, 628.051 628.451, 628.461, 628.4615, 628.471, 628.801, 629.081, 629.091, 629.225, 629.227, 629.291, 634.041, 634.252, 634.304, 634.305, 634.306, 634.307, 634.3073, 634.315, 634.404, 634.407, 634.408, 634.4085, 636.065, 636.005, 636.007, 636.008, 636.009, 636.204, 636.220, 636.226, 636.228, 636.234, 636.236, 641.21, 641.22, 641.227, 641.29(1), 641.255, 641.405, 641.406, 641.407, 641.409, 641.412, 641.416, 641.42, 641.427, 641.43, 641.441, 642.019, 642.021, 642.032, 651.0215, 651.022, 651.023, 651.024, 651.0245, 651.0246, 651.043 FS.

Adopted by Florida Register Volume 48, Number 130, July 6, 2022 effective 7/21/2022, Amended by Florida Register Volume 49, Number 248, December 26, 2023 effective 1/7/2024, Amended by Florida Register Volume 51, Number 053, March 18, 2025 effective 3/31/2025.

New 7-21-22, Amended 1-7-24.

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