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

• Excise (Oregon Dept. of Revenue)
• Insurance amended tax return (iReg Portal)
• Ocean Marine Report by Foreign or Alien Insurers (440-3935)
• Insurance tax (iReg Portal)
• Retaliatory tax calculation for Non-Domestic Legal Expense Organizations: PDF | Excel (440-4879)
• Risk retention tax (iReg Portal)
• Surplus lines licensee affidavit for purchasing groups: Word (440-3928)

Other forms

• Annual Report of Segregated Premiums: PDF (440-4997)
• Form I.S.S. and instructions: Word (440-2035)
• Form C.S.S. and instructions: Word (440-2036)
• Medical/Dental negligence claim report (440-1962)
• Prompt payment data report page: Instructions and forms