Annual/Quarterly Statement Filing Instructions & Forms
- Life
- Property and Casualty / Registered Risk Retention Groups
- Title
- Fraternal
- Health Entities
- Farm Mutual
- Accredited_Reinsurer
Schedule of Company Fees, Taxes and DepositsAnnual 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
- Statement of Condition (Life Companies)
- Statement of Condition (Non-Life Companies)
- 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.
- Indiana Farm Mutual Annual Statement Blank
- Sample of Indiana Farm Mutual Annual Statement Blank
- Indiana Fee and Retaliatory Fee Statement
- Premium Tax
Accredited Reinsurer
- Annual Statement (including Actuarial Opinion and Management's Discussion & Analysis) in hard copy form;
- Most recent Audited Financial Statement;
- AR-1 Form
NOTE: Quarterly statements do not need to be filed.
Please submit this information to the attention of:
Pamela Walters
Property & Casualty Supervisor
Indiana Department of Insurance
311 West Washington Street, Suite 300
Indianapolis, Indiana 46204-2787
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