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Special Reporting Forms
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Last Updated: April 6, 2018
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HMO Data Collection (OCI 26-903) (Administrative Code repealed.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:
Certification of Managed Care Plan Type (OCI 26-109)
Certification of Access Standards (OCI 26-110)
Certification of Preferred Provider Plan Same Service Provisions (OCI 26-112)
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)
