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Forms and applications


Forms for insurers and other entities

Certificate of authority application (NAIC website)

This application applies to the following groups:

  • Domestic home protection
  • Domestic insurer
  • Foreign or alien home protection insurer
  • Health Care Service Contractor (HCSC)
  • Insurance companies
  • Instructions for workers’ compensation carriers

Affidavit for lost certificate of authority: PDF (440-2361)

Amended certificate of authority application (NAIC website)

Application for reservation of name: PDF (440-5873)

Health Care Service Contractor bond: Word | PDF (440-3117)

Home protection insurer bond: PDF (440-2805)

Organizational bond: PDF (440-3094)

Permit to organize insurer with or without capital stock application: PDF (440-3106)

Change of registered office and registered agent by insurer: PDF (440-3310) | Instructions

Forms A though F

  • Statement regarding the acquisition of control of merger with a domestic insurer - Form A: Word (Exhibit 1: OAR 836-027-0100)
  • Insurance holding company system annual registration - Form B: Word (Exhibit 2: OAR 836-027-0010)
  • Summary of registration statement - Form C: Word (Exhibit 3: OAR 836-027-0012)
  • Prior notice of a transaction - Form D: Word (Exhibit 4: OAR 836-027-0160)
  • Pre-acquisition notification - Form E: PDF (Exhibit 5: OAR 836-027-0125)
  • Enterprise risk report - Form F: Word (Exhibit 6: OAR 836-027-0140)

Multiple employer welfare arrangement

  • Application for Certificate of Multiple Employer Welfare Arrangement: PDF (440-3132)
  • Multiple employer welfare arrangement bond PDF (440-3630)

Rating organizations

  • Rating organization license application: PDF (440-3246)
  • Rating organization amended license application: PDF (440-3247)

Security deposit

  • Security deposit release general request: PDF (440-3461)
  • Security Deposit Exchange and Placement Form​: ​PDF (440-5376)
  • Security deposit release request for workers' compensation: PDF (440-2944)

Tax forms

Other forms