69O-136.100 : Forms Incorporated by Reference - Florida Administrative Rules, Law, Code, Register

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Rule: 69O-136.100 Prev Up Next

Rule Title: Forms Incorporated by Reference
Department:	DEPARTMENT OF FINANCIAL SERVICES	Add to MyFLRules Favorites
Division:	OIR – Insurance Regulation
Chapter:	APPLICATION PROCEDURES FOR COMPANIES SEEKING TO DO BUSINESS IN FLORIDA

Latest version of the final adopted rule presented in Florida Administrative Code (FAC):

	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.
	References in this version:	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

History of this Rule since Jan. 6, 2006

Section	Description	ID	Publish Date

Final 69O-136.100	Forms Incorporated by Reference	29368125	Effective: 03/31/2025
Proposed 69O-136.002 ......	To implement 2024-182, Laws of Florida, incorporate all forms in Chapter 69O-136, F.A.C., into Rule 69O-136.100, F.A.C., update the referenced forms and update the lists of forms required to be submitted with each application.....	29112530	12/30/2024 Vol. 50/252
Development 69O-136.002 ......	To implement 2024-182, Laws of Florida, incorporate all forms in Chapter 69O-136, F.A.C., into Rule 69O-136.100, F.A.C., and update the lists of forms required to be submitted with each application.	28935117	10/31/2024 Vol. 50/214
Withdrawal 69O-136.006 ......	Domestic Insurers Filing for an Application for Permit and Subsequent Certificate of Authority, Health Maintenance Organizations, Multiple-Employer Welfare Arrangements, Continuing Care Contracts, Prepaid ....	28746452	9/11/2024 Vol. 50/178
Proposed 69O-136.006 ......	To implement 2024-182, Laws of Florida, incorporate all forms in Chapter 69O-136, F.A.C., into Rule 69O-136.100, F.A.C., and update the lists of forms required to be submitted with each application.	28445364	6/13/2024 Vol. 50/116
Development 69O-136.006 ......	Rule 69O-136.006 is amended and Rules 69O-136.070 and 69O-136.075 are created to implement Chapter 2024-182, L.O.F., regarding changes to Chapter 629 regulating reciprocal insurers. The changes also incorporate all forms ....	28363205	5/15/2024 Vol. 50/96
Final 69O-136.100	Forms Incorporated by Reference	27890039	Effective: 01/07/2024
Correction 69O-136.002 ......	Foreign and Alien Insurers Filing for a Certificate of Authority, Surplus Lines, Domestic Insurers Filing for an Application for Permit, Redomestication Procedure, Domestic Insurers Filing for a Certificate ....	27800023	11/20/2023 Vol. 49/225
Proposed 69O-136.002 ......	OIR is updating chapter 69O-136.	27585362	9/25/2023 Vol. 49/186
Development 69O-136.002 ......	OIR is updating Chapter 69O-136.	27355569	7/21/2023 Vol. 49/141
Final 69O-136.100	Forms Incorporated by Reference	26044032	Effective: 07/21/2022
Proposed 69O-136.080 ......	69O-136.080 and 69O-136.090 concern the acquisition and mergers of insurers and specialty insurers and incorporates the required forms in 69O-136.100.	25741780	4/8/2022 Vol. 48/69
Development 69O-136.080 ......	Rules 69O-136.080 and 69O-136.090, F.A.C. concern the acquisition of insurers and specialty insurers and incorporates the required forms in Rule 69O-136.100 F.A.C.	25390252	12/23/2021 Vol. 47/247
Withdrawal 69O-136.080 ......	Mergers and Acquisition of Controlling Stock of a Florida Domestic Insurer, Merger, Consolidation, or Acquisition of Controlling Stock, Ownership Interests, Assets, or Control of a Specialty Insurer, ....	25358921	12/14/2021 Vol. 47/240
Public Hearing 69O-136.080 ......	The Office of Insurance Regulation is holding a hearing for public input on the notice of change published for proposed rule 69O-136.100 and .... Monday, October 4, 2021, 3:00 p.m. Access via telephone at (850)413-1558 and enter conference ID# ....	24831726	8/3/2021 Vol. 47/149
Change 69O-136.100	Forms Incorporated by Reference	24795739	7/26/2021 Vol. 47/143
Proposed 69O-136.080 ......	69O-136.080 and 69O-136.090 concern the acquisition and mergers of insurers and specialty insurers and incorporates the required forms in 69O-136.100.	24512305	5/10/2021 Vol. 47/90
Development 69O-136.080 ......	69O-136.080 and 69O-136.090 concern the acquisition of insurers and specialty insurers and incorporates the required forms in 69O-136.100.	24181632	2/5/2021 Vol. 47/24

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