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Bureau of Insurance

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Miscellaneous Forms/Reports for Insurers

Insurance Holding Companies Forms (14 VAC 5-260)
- In portable document format (PDF)
- In Micrsoft Word format (doc)
Credit Insurance Experience Exhibit
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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