Florida Department of State and Division of Library and Information Services
Notice: 29368125
Final Adopted Version in F.A.C.
Department: DEPARTMENT OF FINANCIAL SERVICES
Division: OIR – Insurance Regulation
Chapter: APPLICATION PROCEDURES FOR COMPANIES SEEKING TO DO BUSINESS IN FLORIDA

VIEW NOTICE

Overview
RULE:
69O-136.100   Forms Incorporated by Reference
RULE FILE DATE: 3/11/2025
RULE EFFECTIVE DATE: 3/31/2025
HISTORY NOTES: 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. History–New 7-21-22, Amended 1-7-24, 3-31-25.
OVERSIGHT COMMITTEE: Joint Administrative Procedures Committee
Florida Administrative Law Central Online Network (F.A.L.C.O.N.)
RELATED COURT CASES: Division of Administrative Hearings
FEDERAL RULES
AND REGULATIONS: 		Electronic Code of Federal Regulations
HOW TO LINK TO
THIS NOTICE: 		http://flrules.org/gateway/ruleno.asp?id=69O-136.100&Section=0
REFERENCE MATERIALS: Ref-14441 Uniform Certificate of Authority Application (UCAA) Biographical Affidavit
Ref-14442 Disclaimer of Control - Individual
Ref-14443 Disclaimer of Control - Entity
Ref-14444 Uniform Certificate of Authority Application (UCAA) Uniform Consent to Service of Process
Ref-14445 Disclaimer of Control – Investment Companies
Ref-14448 UCAA Proforma Financial Statements, Property and Casualty Insurance Company
Ref-14450 UCAA Proforma Financial Statements, Health
Ref-14593 UCAA Proforma Financial Statements, Title Insurance Company
Ref-16192 OIR-B1-PCR3, Filing requirements Advisory Organization
Ref-16193 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
Ref-16194 OIR-C1-0500, UCAA Biographical Affidavit Addendum Blank
Ref-16195 OIR-C1-0501, UCAA Biographical Affidavit Addendum Education
Ref-16196 OIR-C1-0502, UCAA Biographical Affidavit Addendum Employment
Ref-16197 OIR-C1-0503, UCAA Biographical Affidavit Addendum General
Ref-16198 OIR-C1-0504, UCAA Biographical Affidavit Addendum Licenses
Ref-16199 OIR-C1-0505, UCAA Biographical Affidavit Addendum Professional
Ref-16200 OIR-C1-0506, UCAA Biographical Affidavit Addendum Residence
Ref-16201 OIR-C1-0507, UCAA Biographical Affidavit Addendum Societies
Ref-16202 OIR-C1-0508, “Uniform Certificate of Authority Application (UCAA) Affidavit of Lost Certificate of Authority
Ref-16203 OIR-C1-0509, Uniform Certificate of Authority Application (UCAA) Biographical Affidavit Cover Letter Holding Company Structure
Ref-16206 OIR-C1-0510, “Uniform Certificate of Authority Application (UCAA) Corporate Amendments Application Application to Amend Certificate of Authority
Ref-16208 OIR-C1-0511, Uniform Certificate of Authority Application (UCAA) Corporate Amendments Application Checklist for Corporate Amendments Application Only
Ref-16210 OIR-C1-0512, Uniform Certificate of Authority Application Questionnaire for Adding or Deleting Lines of Business to an Existing Certificate of Authority
Ref-16214 OIR-C1-0522, “Uniform Certificate of Application (UCAA) Change of Mailing Address/Contact Notification Form
Ref-16229 OIR-C1-916, Application for Eligibility as a Surplus Lines Insurer
Ref-16230 OIR-C1-1413, Uniform Certificate of Authority Application (UCAA) Expansion Application
Ref-16231 OIR-C1-1414, Uniform Certificate of Authority Application (UCAA) Expansion Application Checklist For Expansion Application Only
Ref-16232 Form OIR-C1-1416, Uniform Certificate of Authority Application (UCAA) Lines of Insurance
Ref-16233 OIR-C1-1422, Uniform Certificate of Authority Application Questionnaire
Ref-16234 OIR-C1-1424, Uniform Certificate of Authority Application
Ref-16235 OIR-C1-1522, Primary Application Florida Specific Information
Ref-16238 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
Ref-16239 OIR-C1-PCR1, Application for License Rating Organization
Ref-16761 OIR-D0-904, UCAA Proforma Financial Statements, Life & Health Insurer
Ref-17411 OIR-A3-110, License Continuance Form Service Warranty Association
Ref-17413 OIR-A3-453, Premium Finance Company Surety Bond
Ref-17414 OIR-A3-455, Home or Service Warranty Association Surety Bond
Ref-17415 OIR-A3-467 LR, Application for License Continuance Motor Vehicle Service Agreement Company
Ref-17416 OIR-A3-478, Legal Expense Insurance Corporation Surety Bond
Ref-17417 OIR-A3-955, License Continuance Form Service Warranty Association Manufacturer or Affiliate
Ref-17418 OIR-A3-1073, Application for Renewal of License Home Warranty Association
Ref-17419 OIR-A3-1077, Application for License Continuance Legal Expense Insurance
Ref-17420 OIR-A3-1563, Application for Renewal of License Premium Finance Company
Ref-17423 OIR-C1-144, Service of Process Consent & Agreement
Ref-17424 OIR-C1-150, Application for Acquisition of the Attorney-in-Fact of a Domestic Reciprocal Insurer
Ref-17425 OIR-C1-151, Application for Certificate of Authority Domestic Reciprocal Insurer
Ref-17426 OIR-C1-152, Letter of Notification Acquisition of the Attorney-in-Fact of a Domestic Reciprocal Insurer
Ref-17427 OIR-C1-153, Application for Merger or Conversion Reciprocal Insurer
Ref-17428 OIR-C1-448, Application for Acquisition of Controlling Stock, Ownership Interest, Assets, or Control of a Florida Specialty Insurer; Merger or Consolidation
Ref-17430 OIR-C1-454, Personal Financial Statement
Ref-17431 OIR-C1-471, Application for Provisional Certificate of Authority for a Continuing Care Provider
Ref-17432 OIR-C1-473, Application for Certificate of Authority for a Continuing Care Provider
Ref-17433 OIR-C1-480, Application for Certificate of Authority Legal Expense Insurance
Ref-17434 OIR-C1-483, Application for Certificate of Authority Prepaid Health Clinic
Ref-17437 OIR-C1-513, Application for Registration as a Risk Retention Group
Ref-17442 OIR-C1-918, Application for Acquisition of Controlling Stock of a Florida Domestic Insurer
Ref-17443 OIR-C1-942, Application for Certificate of Authority Health Maintenance Organization
Ref-17445 OIR-C1-958, Application for License Premium Finance Company
Ref-17446 OIR-C1-983, Application for Certificate of Authority Multiple Employer Welfare Arrangement,
Ref-17447 OIR-C1-989, Application for License Service Warranty Association Manufacturer or Affiliate
Ref-17448 OIR-C1-994, Application for License Motor Vehicle Service Agreement Company
Ref-17449 OIR-C1-997, Application for License Service Warranty Association
Ref-17450 OIR-C1-1075, Application for Certificate of Authority of an Insurance Administrator
Ref-17451 OIR-C1-1119, Application for Certificate of Authority Prepaid Limited Health Service Organization
Ref-17452 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.
Ref-17453 OIR-C1-1606, Application for License Discount Plan Organization (DPO)
Ref-17454 OIR-C1-2069, Letter of Notification
Ref-17455 OIR-C1-2218, Application for Expansion of a Certificated Continuing Care Facility
Ref-17457 OIR-C1-2220, Consolidated Application for Provisional Certificate of Authority and Certificate of Authority for a Continuing Care Provider
Ref-17459 OIR-C1-PCR2, License Renewal Rating Organization
Ref-17461 OIR-C1-938, Fingerprints and Social Security Number
Ref-17909 OIR-C1-100, Application for Permit Domestic Stock or Mutual Insurer
Ref-17910 OIR-C1-101, Application to Redomesticate a Stock or Mutual Insurer
Ref-17911 OIR-C1-490, Application for License Home Warranty Association
Ref-17912 OIR-C1-515, Application for Registration as a Risk Purchasing Group
Ref-17913 OIR-C1-845, Application for Certificate of Authority Commercial Self-Insurance Fund
Ref-17914 OIR-C1-908, Application for Permit Domestic Reciprocal Insurer
Ref-17915 OIR-C1-957, Instructions for Statutory Compliance of Forms: Premium Finance Companies
Ref-17916 OIR-C1-2219 Application for the Simultaneous Acquistion of a Continuing Care Facility and Issuance of a COA
Ref-17917 OIR-C1-2221, Management Information Form


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