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Insurer forms and applications - Alphabetical List

Title Form #
Affidavit for Lost Certificate of Authority 2361
Annual Statement of Educational Institutions and Nonprofit Corporations Authorized to Issue Gift Annuities 2315
Application for Amended Certificate of Authority: Word,  PDF 3305
    * Instructions
Application for Certificate of Authority
* Domestic Home Protection  
* Domestic Insurer  
* Educational/Nonprofit 3105
    * Affidavit
* Foreign or Alien Home Protection Insurer  
* Health Care Service Contractor (HCSC)  
* Insurance Companies  
Application for Certificate of Registration for Legal Expense Organization 2167
    * Instructions
Application for Permit to Organize Insurer with or without Capital Stock: Word,  PDF 3106
Application for Renewal of Certificate of Registration for Legal Expense Organization 2170
Application for Reservation of Name  
Change of Registered Office and Registered Agent
 * Insurer 3310
    * Instructions
 * Legal Expense Organization 2169
Designation of Registered Office and Registered Agent
* Insurer 3309
* Legal Expense Organization 2168
External Review Referral Request 3430
External Review Annual Summary: Word 97,  PDF 3639
Financial Statement for Legal Expense Organization 2164
Form I.S.S. and instructions: Word 97,  PDF 2035
Form C.S.S. and instructions: Word 97,  PDF 2036
Health Care Service Contractor Bond 3117
Home Protection Insurer Bond 2805
Legal Expense Insurance List of Sales & Marketing Representatives 2166
Life Settlement Provider Application Packet
* Disclosure Statement for Life Settlement Contracts
* Application for License as Life Settlement
     Provider: Word 97,  PDF
* Life Settlement Broker Appointment/Affiliation Notice
Life Settlement Provider Bond 3359
Medical/Dental Negligence Claim Report:
     Word 97,  PDF
    * Instructions
Multiple Employer Welfare Arrangement Bond 3630
OIGA Assessment Recoupment  
Oregon Biographical Affidavit 3095
Oregon Special Schedule P: Excel,  PDF 3112
* For Insurers authorized to write workers' compensation
Organizational Bond 3094
Patient Protection Reporting Forms
* Grievance Annual Report: Word 97,  PDF 3241
* Quality Assessment Annual Summary: Word 97,  PDF 3239
* Network Adequacy Annual Summary: Word 97,  PDF 3237
* Utilization Review Annual Summary: Word 97,  PDF 3238
Prompt Payment Data Report
    * For health insurers and health care service contractors
    * Instructions
Qualifying Bond for Legal Expense 2165
Quarterly Enrollment Reporting Form: Excel,  PDF 3118
    * Instructions
Rating Organization License Application: Word 97,  PDF 3246
Rating Organization
Amended License Application: Word 97,  PDF
Security Deposit Release Request: Word 97,  PDF 2944
Service Contracts Obligor Registration Application 2851
    * Instructions
Surplus Lines Licensee Affidavit for Purchasing Groups: Word 97,  PDF 3928

Statement Regarding the Acquisition of Control of Merger with a Domestic Insurer Form A
Insurance Holding Company System Annual Registration Form B
Summary of Registration Statement Form C
Prior Notice of a Transaction Form D

Tax Forms
* Excise  
* Life and Health 20012002200320042005  
* Ocean Marine 20042005  
* Property & Casualty 20012002200320042005  
* Risk Retention 200320042005  

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This document was last revised on January 20, 2006 .