Annual/Quarterly Statement Filing Instructions & Forms
Schedule of Company Fees, Taxes and Deposits
Annual Filing Forms for Insurance Companies: Foreign Insurance Companies are no longer required to submit a hard copy or diskette of their Annual or Quarterly Statements to Indiana as of yearend 2002. Some state specific items are required electronically and in hardcopy (see checklist).
Note: Premium tax filings are to be received on or before the due date indicated at the address on the instructions.
All other filings are due on the dates indicated on the checklist; postmark date is acceptable and if the due date falls on the weekend the filing is due on the next workday.
Life
Access the Instructions and checklist
State Required Forms
- Basket Clause Form (Paragraphs 19 & 20)(Domestic Only)
- Certificate of Advertising Compliance
- Foreign Investments and Other Structured Securities [IC 27-1-12-2(b)(17A), (17B) & (30A)]
- Indiana Fee and Retaliatory Fee Statement
- Insurer Profile Questionnaire
- Premium Tax
- Statement of Condition* (Foreign Only)
- Supplement to the State of Indiana Health Exhibit (ICHIA)
Property and Casualty
Access the instructions and checklist
State Required Forms
- Basket Clause Form (Paragraphs 19 & 20) (Domestic Only)
- Certificate of Advertising Compliance
- Foreign Investments and Mortgage Backed Securities Report[IC 27-1-13-3(c)(9), (17) & (19)
- Indiana Fee and Retaliatory Fee Statement
- Insurer Profile Questionnaire
- Premium Tax
- Statement of Condition (Foreign Only)
- Supplement to the State of Indiana Health Exhibit (ICHIA)
Title
Access the instructions and checklist
State Required Forms
- Basket Clause Form (Paragraphs 19 & 20) (Domestic Only)
- Indiana Fee and Retaliatory Fee Statement
- Insurer Profile Questionnaire
- Premium Tax
Fraternal
Access the instructions and checklist.
State Required Forms
- Basket Clause Form (Paragraphs 19 & 20) (Domestic Only)
- Certificate of Advertising Compliance
- Foreign Investments and Other Structured Securities [IC 27-1-12-2(b)(17A), (17B) & (30A)]
- Indiana Fee and Retaliatory Fee Statement
- Insurer Profile Questionnaire
- Supplement to the State of Indiana Health Exhibit (ICHIA)
Health Entities
Access the instructions and checklist.
State Required Forms
- Analysis of Operations by Line of Business
- Annual Minimum Net Worth Calculation Form HMO
- Basket Clause Form (Paragraphs 19 & 20) (Domestic Only)
- Certificate of Advertising Compliance
- Foreign Investments and Other Structured Securities [IC 27-1-12-2(b)(17A), (17B) & (30A)]
- Foreign Investments and Mortgage Backed Securities Report[IC 27-1-13-3(c)(9), (17) & (19)
- Indiana Fee and Retaliatory Fee Statement
- Insurer Profile Questionnaire
- Plan for Receivership per IC 27-13-16-1 & Rule 70 (applicable to HMO's only)
- Premium Tax
- Quarterly Minimum Net Worth Calculation Form HMO Page 1, Page 2, and LSHMO
- Supplement to the State of Indiana Health Exhibit (ICHIA)
- Supplement Report-6A Form
- Supplemental Report #2 - Point of Service
Farm Mutual
Access the instructions and checklist
The Farm Mutual Filing forms are provided below. To download the forms please click on them individually.
- I have a complaint against my insurance company, who do I contact?
- How do I file a complaint against an insurance company?
- Where can I find out about insurance law in Indiana?
- How do I file a complaint against a qualified health care provider?
- How do I find out more about COBRA coverage?
- What if I have a self-insured health plan? What is ERISA? Why can't the state de...
- Am I eligible for Medicare?
- How can I ensure that I will be notified when updates to Indiana Insurance rules...
- What does Medicare cover?
- How much does Medicare cost?
- File a complaint.
- Become an insurance producer.
- Check out a health care provider.
- Find a company's registered agent.
- See a list of licensed insurance companies.
- File a medical malpractice complaint.
- Learn about Medicare.
- Compare Medicare Supplement plans.
- See what enforcement actions IDOI has taken.
- Learn about COBRA coverage.
- Know my HIPAA rights.
- Form an insurance company.
- File financial information for my insurance company.
- Qualify under Indiana's Medical Malpractice Act.
- Find a bail bond company.
- Contact SHIP for information.
