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• Expedited Branch Relocation Application and Certification
• Expedited Auxiliary Office Application and Certification Form
• Expedited Branch Application
  and Certification Form (PDF)
• Expedited Interchange of
  Principal and Branch Office Application and Certification (PDF)
• Expedited Mini Branch Application and Certification Form (PDF)
• Expedited Principal Office Relocation Application and Certification Form (PDF)

• Branch Office Application for Out-of-State Banks
• Branch Relocation Application for Out-of-State Banks
• Branch Office Relocation Application
• Full Service Branch Office Application
• Main Office Relocation Application
• Mini-Branch Office Application
• Application to Establish a Domestic Operating Subsidiary (N.J.A.C. 3:11-5) (MS Word)

   

• Real Property Transaction (Form 114)
  • Schedule A - Purchase Transaction
  • Schedule B - Leasehold
  • Schedule C - Sale Leaseback

• Affidavit - Increase in Capital Stock of a Bank
• Request to Issue Authorized but Unissued Capital Stock
• Stock Dividend Under Section 52

• N.J.A.C. 3:7-5.1 et seq. on content and filing of Statements of Interest by directors and executive officers of banks
• SI-1 (for reporting a relationship with a business enterprise that DOES NOT have a relationship with the bank)
• SI-2 (for reporting a relationship with a business enterprise that DOES have a relationship with the bank)

• Individual Producer Renewal Application (Resident or Nonresident) (PDF)
• Business Producer Renewal Application (Resident or Nonresident) (PDF)
• Individual Public Adjuster Renewal Form (PDF)
• Organization Public Adjuster Renewal Form (PDF)
• Initial Individual Producer License Application (Resident or Nonresident) (PDF)
• Initial Business (Corporation/Partnership) Insurance Producer License Application (PDF)
• Initial Individual (or Sublicensee) Public Adjuster License (Resident or Nonresident) (PDF)
• Initial Organization (Corporation/Partnership) Public Adjuster License (Resident or Nonresident) (PDF)
• Reinsurance Intermediary Authorization Application
  • Form A - Notice of Reinsurance Intermediary Manager (PDF)
  • Form B - Notice of Termination of Reinsurance Intermediary Manager (PDF)
  • Form C - Application for Resident or Nonresident Organization, Corporation/Partnership or Individual Reinsurance Intermediary Authorization (PDF)

• Additional Authority Request Form (PDF)
• Request for Certification Letter
• Branch Office Registration
• Notice of Agency Contract
• Notice of Termination of Agency Contract
• Notice of Managing General Agent Contract
• Public Adjuster Bond
• Business/Trade Name Approval Form (PDF)
• Change of Designated Responsible Producer Form (PDF)
• Request for Surrender or Status Change (PDF)
• Change of Address (PDF)

• Criminal History Records/Fingerprinting
• Important Notice - Child Support Arrearages Law
• Branch Office Rule - N.J.A.C. 11:17-2.9

• Continuing Education Designation Form (PDF)
• Alternative Continuing Education Credit Application (PDF)
• Prelicensing Education Waiver Application (PDF)
• Insurance Education Provider Application (PDF)

• National Uniform CE Application Form (PDF)
• Request for Certification Letter

• Admission and Uniform Certificate of Authority Application (UCAA) Forms
• Plain Language - Affidavit of Compliance - Exhibit A
• Plain Language - Affidavit of Compliance - Exhibit B
• Annual Statement Checklists and Instruction Letters NEW
  
• Anti-Fraud Prevention & Detection Experience Annual Report - Automobile Insurers
  • Instructions/Definitions
  • Annual Report
    
• Anti-Fraud Prevention & Detection Experience Annual Report - Health Insurers
  • Instructions/Definitions
  • Annual Report
• Application for Listing as an Approved NJ Surety (PDF)
• Attending Provider Treatment Plan Form (PIP) - PDF or MS Excel
• (PDF)
• Certification of Compliance pursuant to N.J.A.C. 11:3-32 (PDF)
• Certification of Compliance pursuant to N.J.A.C. 11:3-8.11 (PDF)
• Consent to Higher Rate Forms
  • Automobile Insurance (PDF)
  • Fire and Allied Lines (PDF)
  • Other Lines (PDF)
• Deposit and Custodial Account Forms
  • Deposit/Substitution Request Form (PDF)
  • Step by Step Instructional for Request Form (PDF)
  • Custodial Account Information/Contact Change Form (PDF)
• E-mail Contact Designation (PDF)
• Health Claims Payment Appeal Application (for carrier modification) - MS Word or PDF
• Insurance Premium Taxes, Assessments and Surcharge Forms
  Contact information: Tanveer Ahmed, (609) 940-7411
  
• Annual Report of Premiums Paid to Risk Retention Groups (PDF)
• Ocean Marine Tax Report (PDF)
• Report and Reconciliation of N.J. Property-Liability Insurance Guaranty Association Surcharge (PDF)
• Loss Cost Filing Adoption Form (Commercial) (PDF)
• Loss Cost Filing Adoption Form (Personal) (PDF)
• Private Passenger Auto, ³Ô¹ÏºÚÁÏowner and Medical Malpractice Reports
• Producer Controlled Insurance Company
  • Report Letter (PDF)
  • Report Form (PDF)
• Service of Process (Appointment of Commissioner) (PDF)

HINT Enrollment

• Group Enrollment/Change Request -
  MS Word or PDF
• Non-Group Enrollment/Change Request -
  MS Word or PDF
• Non-Group Product Conversion Request -
  MS Word or PDF

Sample Notices for Withdrawals and Block Non-Renewals

• Policyholder Final Notice Single Line (PDF)
• Policyholder Final Notice Multiple Lines (PDF)
• Intent To Withdraw Notice Single Line (PDF)
• Intent To Withdraw Notice Multiple Lines (PDF)
• Block Non Renewal Notice (PDF)

• Medicare Only Application - MS Word or PDF
  or
  
• All Other HMO Application - MS Word or PDF
  Attachments:
  • Physicians by Region - North (PDF)
  • Physicians by Region - Central (PDF)
  • Physicians by Region - South (PDF)
  • Summary of Physicians by County (PDF)
  • General Acute Care Hospitals (PDF)
  • Summary of Ancillary, Tertiary and Specialized Providers by County (PDF)
  • Capital and Surplus Guaranty (PDF)
  • Provider Agreement Certification (Fillable MS Word - Download document and type or select your answers, where applicable; print out completed form; affix the appropriate signatures)
    
    
    
• HMO Annual Supplement Forms
  • Commercial (MS Excel)
  • Medicaid (MS Excel)

• SCA Application (PDF)
  
  Attachments:
• General Acute Care Hospitals (PDF)
• Ancilliary and Specialized Providers by County (PDF)
• Dental Providers Only (PDF)
• Vision Providers Only (PDF)
• Summary of Physicians by County (PDF)
• Physicians by Region - North (PDF)
• Physicians by Region - Central (PDF)
• Physicians by Region - South (PDF)
• Provider Agreement Certification (Fillable MS Word - Download document and type or select your answers, where applicable; print out completed form; affix the appropriate signatures)
  
  
• SCA Annual Report (MS Excel)

Dental Plan Organizations (DPO) and Dental Service Corporations (DSC)

• DPO Application (Application is currently under revision; contact for more information)
• DPO - Annual and Quarterly Filings (PDF)
  
  
• DSC Application to obtain a Certificate of Authority (COA) Part I (PDF)
• DSC Application to obtain a Certificate of Authority (COA) Part II (PDF)

Workers’ Compensation Managed Care Organization (WCMCO)

• WCMCO Application (PDF)
  
  Attachments:
  
  • Ambulatory Site Contacts (PDF)
  • General Acute Care Hospitals (PDF)
  • Summary of Ancillary, Tertiary and Specialized Providers by County (PDF)
  • Summary of Physicians by County (PDF)
    
    
• WCMCO Annual Report (PDF)
  
  
• WCMCO Annual Financial Filing (PDF)

Organized Delivery Systems (ODS)

• Application for certification (PDF) - To be completed by entities that will be compensated on a basis that entails no assumption of financial risk.
  
  Attachments
  • Summary of Physicians by County (PDF)
  • Physicians by Region - North (PDF)
  • Physicians by Region - Central (PDF)
  • Physicians by Region - South (PDF)
  • General Acute Care Hospitals (PDF)
  • Summary of Ancillary, Tertiary and Specialized Providers by County (PDF)
  • Dental Providers Only (PDF)
  • Vision Providers Only (PDF)
  • Provider Agreement Certification (Fillable MS Word - Download document and type or select your answers, where applicable; print out completed form; affix the appropriate signatures)
    
    
• Certified Organized Delivery System (CODS) Annual Report

• Application for licensing (PDF) - To be completed by entities that will be compensated on a basis that entails the assumption of financial risk, as defined at N.J.A.C. 11:22-4.2.
  
  

• Complaints about managed care - PDF or MS Word
• HCQA Registration - PDF or MS Word
• NJ Universal Physician Application
• NJ Physician Recredentialing Application
• Provider Agreement Certification and Checklist - PDF or Fillable MS Word
• Hemophilia Designation Checklist - PDF or MS Word
• IHCAP External Appeal application
• IHCAP External Appeal (MEDICAID) application

• Claims Payment Appeal Form (for carrier modification) - MS Word or PDF; Instructions (PDF)
• Claims Payment Appeal Form (generic, for use by health care providers) - MS Word or PDF
• Consent to Representation and Release of Medical Information (with blanks for use by health care providers) - MS Word or PDF; Instructions (PDF)
• Notice of Intent to File an Appeal (for use by health care providers)
  • Stage 1 - MS Word or PDF; Instructions (PDF)
  • Stage 2 - MS Word or PDF; Instructions (PDF)
  • Stage 3 (IHCAP) - MS Word or PDF; Instructions (PDF)

• Application for Special Permit (PDF)

• Annual Report of Premiums Paid to Risk Retention Groups (PDF)
• Ocean Marine Tax Report (PDF)
• Report and Reconciliation of N.J. Property-Liability Insurance Guaranty Association Surcharge (PDF)

• Application for Registration as a Risk Retention Group (PDF)

• Application for Registration as a Purchasing Group (PDF)

• Application for Real Estate School License for Public School (PDF)
• Application for Non-Public Real Estate School License (PDF)
• Application for Additional Non-Public Prelicensure School Teaching Location (PDF)
• Change of Address - Real Estate School (PDF)
• Change of School Director (PDF)
• Change of Name for Real Estate School (PDF)
• Fingerprinting for Instructors; Directors/Principals of Real Estate Schools

• Information to Become a Pre-Licensed Instructor (PDF)
• School Closing Affidavit (PDF)
• Pre-Licensure Instructor Application: MS Word or PDF

• Application for Registration Questionnaire (PDF)
• Exemption Application/Affidavit (PDF)
• Registration and Inspection Fee (PDF)
• Broker/Developer Application (PDF)
• Statement of Non-Conviction (PDF)
• Irrevocable Consent to Service of Process (PDF)
• NJ Public Offering Statement Format (Non-Timeshare) (PDF)
• NJ Disclosure Statement (For those offerings utilizing a HUD Property Report or Situs State Public Offering Statement in lieu of a ³Ô¹ÏºÚÁÏ format offering statement. See N.J.S.A. 45:15-16.41(a) and N.J.A.C. 11:5-9.3(a) 6 and 7, for further information) (PDF)
• Secondary Registration Application

• Timeshare Registration Application Questionnaire (PDF)
• Timeshare Consent to Service of Process (PDF)
• Timeshare Non Conviction Statement (PDF)
• Timeshare Broker/Developer Application/Affidavit (PDF)
• Timeshare Public Offering Statement Format (Single Site or Specific Interest Offering) (PDF)
• Timeshare Public Offering Statement Format (Non Specific Interest) (PDF)
• Timeshare Public Offering Statement Format (Preliminary Registration Only) (PDF)
• Non Binding Reservation Agreement (Preliminary Registration Only) (PDF)
• Timeshare Inspection (PDF)