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Forms and Applications

Agents/Brokers Forms and Applications:

• All License Types – License and Renewal Information
• Address Change Form (not for moving into or out of Connecticut)
• Continuing Education
• DBA Update Form (Doing Business As)
• Designated Responsible Licensed Producer (DRLP) Update Form
• Letter of Certification
• Letter of Clearance Request (Residents ONLY)
• License Voluntary – Surrender Request
• Name Change Request Form
• Print Your Receipt
• Residency Change Request form (for moving into or out of Connecticut)
• Update License Information (email, demographics, etc.)
• View CE Transcript, Approved CE Courses and CE Course Providers

Bail Bonds Forms and Applications:

• Bail Bonds Regulation

Captive Insurance Forms and Applications:

• Actuary Loss Reserve Certification
• Biographical Affidavit
• Captive Insurance Company Manager
• Certified Public Accountant
• Change in Registration for Risk Purchasing Groups
• Corporate Governance Guidance
• Form 115NIN – Nonadmitted Insurance Premium Tax Return Form
• Form 115RRG – Tax Return Form for Foreign Risk Retention Group
• License Application Form
• NAIC Risk Purchasing Group Part A and B Application Form
• NAIC Uniform Risk Retention Group Notice and Registration Form
• Sample Letter of Credit
• Tax Return Form 207C

Consumer Forms:

• Behavioral Health Consumer Tool Kit
• Connecticut Continuation Coverage Election Notice
• Consumer Complaint Form (PDF - Fillable Form)
• CT Surety Liquidation Claim Form
• External Review Program Flyer
• Request for External Review form (Effective October 1^st, 2021)
• Infertility Treatment & Procedures Disclosure Form
• Request for Authorization of coverage of Routine Patient Care Costs Associated with Cancer Clinical Trials
• Surety Bail Bond Agent Complaint Form

Insurer Forms and Applications:

• Accredited Reinsurers:
  • Procedures for recognition as an accredited reinsurer
  • AR1 Form - Certificate of Assuming Insurer
  • Uniform Consent to Service of Process
• Annual Financial Filing Requirement:
  • Fraternal Societies
  • Health Insurers
  • Life, Accident and Health Insurers
  • Property and Casualty Insurers
  • Retention of Assets Statement
  • Title Companies
• Connecticut Data Security Forms:
  • Cybersecurity Exception Certification Form
  • Cybersecurity Notification Form (Complete this form and email to cid.mc@ct.gov along with all attachments require)
  • Data Security Law Annual Certification Form
• Consumer Report Card:
  • Consumer Report Card Survey - Part 1 (Five worksheets in this excel workbook)
  • Consumer Report Card Survey - Part 2 (Seven worksheets in this excel workbook)
  • Consumer Report Card Addendum (all networks)
• CT Surety Liquidation Bond Loss Claims Form
• Family Health Statement for CSEHRP
• Fraud Report Instructions
• Formulary Survey
• Health and Welfare Fee Assessment Reporting Form: Childhood Immunization Vaccine Assessment
• Health Care Centers/Insurance Companies Forms and Application
• Insurance Fraud Report Online Portal
• Managing General Agent (MGA) Application
• Network Adequacy Survey:
  • Network Adequacy Survey - DENTAL
  • Network Adequacy Survey - MEDICAL
  • Network Adequacy Survey - VISION
• Property & Casualty Forms and Checklists
• Professional Employer Organization Annual Certification
• Public Health Fee Assessment Report
• Termination "For Cause" Notice - Online (save your confirmation email as your record)