FIS 2214 Captive Insurer Application. Includes supporting forms and instructions to make application for a Captive Insurer limited certificate of authority.The state specific application checklist is intended to help you assemble a complete Uniform Certificate of Authority Application (UCAA). Upload your current insurance declaration pages to accelerate the proposal process. This form is utilized to add, terminate or change multiple insurance policy information for a beneficiary. You will be required to fill out an "application for car insurance," which may be in paper form or online. How do I fill this out? The director has prescribed any person seeking approval to file a Form A - Statement Regarding the Acquisition of Control of or Merger with a Domestic Insurer. This form is to help you obtain the information that is needed for us to submit your insurance claim. Here you'll find forms relating to your Medicare plan.