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.

Instructions

NAIC Uniform Application for Individual Insurance Producer License

Form 9001 - Nebraska-Specific Insurance Producer's Application

Electronic Non-Resident Producer License

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:
- Memorandum - Viatical Settlement Broker and Provider Licensing
- Procedures to Obtain a Viatical Settlement Broker License
- Declaration to Nebraska Department of Insurance for Viatical Settlement Agent or Broker
- Individual Resident/Nonresident Producer and Viatical Settlement License Application

Viatical Settlement Broker Entity

Includes the following:
- Memorandum - Viatical Settlement Broker and Provider Licensing
- Declaration to Nebraska Department of Insurance for Viatical Settlement Agent or Broker
- 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

Application for Limited License for Sale of Insurance related to Rental Vehicles

Includes instructions.

Midwest Zone Appointment/Termination Form

Includes instructions and form.

Retaliatory Appointment Fees as of March 6, 2007

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

2007 Third Party Administrator Annual Statement form

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

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.