Special Reporting Forms

​​​​​​​​​​​​​Last Updated: September 19, 2023

• 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)
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• Designation of Registered Agent for Service of Process (OCI 12-014)  
  
  
• 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• ​HMO Data Collection (OCI 26-903) (Administrative Code repealed.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
  
  
• Multiple Employer T​rust Filing
  
  
• Reservation of Corporate Name (OCI 23-010)  Fillable
  
  
• Risk Retention Group Pr​emium 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)