Form 2c - Uniform Certificate Of Authority Application
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4Applicant Company Name: _____________________________
NAIC No. _________________________
FEIN:
_________________________
Uniform Certificate of Authority Application (UCAA)
Corporate Amendments Application
Application to Amend Certificate of Authority
To the Insurance Commissioner/Director/Superintendent of the State of:
(Check the appropriate states in which the Applicant Company is applying.)
Alabama
Montana
Alaska
Nebraska
Arizona
Nevada
Arkansas
New Hampshire
California
New Jersey
Colorado
New Mexico
District of Columbia
New York
Connecticut
North Carolina
Delaware
North Dakota
Florida
Ohio
Georgia
Oklahoma
Hawaii
Oregon
Idaho
Pennsylvania
Illinois
Puerto Rico
Indiana
Rhode Island
Iowa
South Carolina
Kansas
South Dakota
Kentucky
Tennessee
Louisiana
Texas
Maine
Utah
Maryland
Vermont
Massachusetts
Virginia
Michigan
Washington
Minnesota
West Virginia
Mississippi
Wisconsin
Missouri
Wyoming
The Uniform Certificate of Authority Corporate Amendments Application can be used to file more than one change in the
same submission. The Applicant Company should mark all changes being filed on the application form and submit all items
required for those changes in one package.
(Check the type of transaction for which the Applicant Company is applying.)
Add Lines of Business: The undersigned Applicant Company hereby certifies that the lines of insurance as
indicated on the Lines of Insurance Form 3 are all lines of business that (a) the Applicant Company is currently
authorized to transact, (b) are currently transacted, and (c) which the Applicant Company is applying to transact.
Name Change
Delete Lines of Business
Redomestication of a Foreign Insurer
Change of city of domicile within domestic state/mailing address
Change of Address/Contact Notification
Merger of Two or More Foreign Insurers
Pre-notification of Change of Control of Foreign Insurer
Notification of Change of Control of Foreign Insurer
Amended Articles of Incorporation
Amended Bylaws
Revised 12/19/14
2016 National Association of Insurance Commissioners
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FORM 2C
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