Nebraska Department of Insurance

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DEPARTMENT FORMS

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PRODUCER (AGENT) LICENSING FORMS

Have questions concerning producer or agency licensing or continuing education matters?
Check our Frequently Asked Questions.

Effective 4/15/09

The Nebraska Department of Insurance is pleased to announce that it is now accepting the following products online through www.nipr.com:

Non-Resident License for Business Entities
Non-Resident Renewals for Individuals and Business Entities
Non-Resident Reinstatements

(Includes Surplus Lines license application)

Instructions

NAIC Uniform Application for Individual Insurance Producer License

(Includes Surplus Lines license application)

Electronic Non-Resident Producer License

(Includes Surplus Lines license application)

Application for Certificate to Transact Business as a Utilization Review Agent

Application and Requirements for Transacting Business as a Managing General Agent

Viatical Settlement Broker

Includes the following:
- Procedures to Obtain a Viatical Settlement Broker License
- Declaration to Nebraska Department of Insurance for Viatical Settlement Agent or Broker

Viatical Settlement Broker Entity

Includes the following:
- Viatical Settlement Broker Business Entity License Application

Insurance Consultant's License

Includes the following:
- Requirements and Procedures for Obtaining an Insurance Consultant's License - Resident and Nonresident

Corporate Insurance Consultant's License

Includes the following:
- Requirements and Procedure for Obtaining a Corporate Insurance Consultant License - Resident and Nonresident

Change Request

Form 9110 - Request Form for Producers and Consultants

Address Change Request form via NAIC

Rental Car Instructions

Agency Uniform application

NAIC Uniform Appointment/Termination Form

Includes instructions and form.

Retaliatory Appointment Fees as of December 2009

National Insurance Producer Registry (NIPR)

Link to the NIPR web site that includes e-mail addresses concerning questions for NIPR, PDB, PIN, and Non-Resident Licensing.

Financial Disclosure Statement - Title Insurance Agent

COMPANY APPLICATION/LICENSING FORMS

Third Party Administrator Packet

Includes instructions and the following form:
- Form TPA - Application for Certificate of Authority

2009 Third Party Administrator Annual Statement form

Significant changes have occurred to this form. Please read carefully.

2009 Pre-Need Seller Annual Report

Pre-Need Agent Application

Pre-Need Seller Application

Viatical Settlement Provider Application

Includes the following:
- Memorandum - Viatical Settlement Broker and Provider Licensing
- Viatical Settlement Provider Application

Purchasing Group-Notice and Registration Form

Includes the following:
- Memorandum - Requirements Under Liability Risk Retention Act of 1986 and Nebraska Risk Retention Act
- Uniform Registration Form - Purchasing Group-Notice and Registration

Purchasing Group Registration Renewal Form and Instructions

Application for Certificate to Transact Business as a Utilization Review Agent

Form 12: Changes or additions to the Uniform Consent to Service of Process form

Changes or additions to the Agent for Service of Process for Nebraska-licensed companies may be accomplished by completion and submission of the NAIC Uniform Certificate of Authority (UCAA) Form 12.