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Miscellaneous Forms/Reports for Insurers
Insurance Holding Companies Forms
(14 VAC 5-260)
In portable document format (PDF)
Form A (pdf) - Instructions for Application for Approval of Acquisition of Control of or Merger with a Domestic Insurer
Form B (pdf) - Instructions for Insurance Holding Company System Annual Registration Statement
Form C (pdf) - Instructions for Summary of Registration Statement
Form D (pdf) - Instructions for a 38.2-1331 Prior Notice and Application for Approval of Certain Transactions
Form E (pdf) - Instructions for an Acquisition Statement Reporting Competitive Impact Data
Form F (pdf) - Instructions for Notice of Dividends and Distributions to Shareholders Pursuant to 38.2-1330 C of the Code of Virginia
In Micrsoft Word format (doc)
Form A (doc) - Instructions for Application for Approval of Acquisition of Control of or Merger with a Domestic Insurer
Form B (doc) - Instructions for Insurance Holding Company System Annual Registration Statement
Form C (doc) - Instructions for Summary of Registration Statement
Form D (doc) - Instructions for a 38.2-1331 Prior Notice and Application for Approval of Certain Transactions
Form E (doc) - Instructions for an Acquisition Statement Reporting Competitive Impact Data
Form F (doc) - Instructions for Notice of Dividends and Distributions to Shareholders Pursuant to 38.2-1330 C of the Code of Virginia
Credit Insurance Experience Exhibit
Credit Insurance Experience Exhibit Filing Instructions
Credit Insurance Experience Exhibit Questionnaire
Company Filing Portal
External Review Forms
Independent Review Organization Forms
IRO Application –
Form 216-E (doc)
(7/11)
IRO Application –
Form 216-E (pdf)
(7/11)
IRO External Review Annual Report –
Form 216-G (doc)
(7/11)
IRO External Review Annual Report –
Form 216-G (pdf)
(7/11)
Health Carrier Form
Health Carrier External Review Annual Report –
Form 216-F (doc)
(7/11)
Health Carrier External Review Annual Report –
Form 216-F (pdf)
(7/11)
Self-insured ERISA Plan Form
Self-insured Plan Opt-in for External Review –
Form 216-H (doc)
(7/11)
Self-insured Plan Opt-in for External Review –
Form 216-H (pdf)
(7/11)
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