Special Reporting Forms

​​​​​​​Last Updated: August  8, 2019

• Amendment to Articles of Organization, Town Mutual (OCI 26-003)
• Biographical Form A (OCI 21-200)
• Care Management Organizations permitted under ch. 648, Wis. Stat.:
• Biographical Data (OCI 33-004)
• CPA Audit Checklist (OCI 33-007)​
• Designation of Registered Agent for Service of Process (OCI 12-014)  Fillable​
• Directly Placed Unauthorized Tax Report (OCI 27-016)  Fillable
• Grievance Reporting Forms
• HMO Data Collection (OCI 26-903) (Administrative Code repealed. No longer required.)
• Individual Uniform Application for Individual Major Medical Health Insurance Form (OCI 26-503)
• Insurance Complaint Form (OCI 51-005)
• Long-Term Care:
  • Issuer Certification Form (OCI 26-113)
  • Policyholder Long-Term Care Partnership Plan Status Form (OCI 26-114)
  • Long-Term Care Reporting Forms
• Managed Care Plan Certifications
• Market Conduct Annual Statement

• Medicare Supplement Reporting Forms
• Reservation of Corporate Name (OCI 23-010)  Fillable
• Risk Retention Group Premium Tax Report (OCI 27-017)  Fillable
• Small Employer Uniform Employee Application for Group Health Insurance (OCI 26-501)
• Statutory Hold-Harmless Forms (Opt-Out/In):
  • Election of Exemption (Opt-Out) (OCI 22-510)
  • Election to be Subject to Restrictions (Opt-In) (OCI 22-520)
  • Termination of Election to be Subject to Restrictions (Termination of Opt-In) (OCI 22-540)
  • Termination of Exemption (Termination of Opt-Out) (OCI 22-530)