Form 2c - Uniform Certificate Of Authority Application Page 2
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4Applicant Company Name: _____________________________
NAIC No. _________________________
FEIN:
_________________________
Previous Name of Applicant Company: _____________________________________ NAIC No. __________________
Previous Group Name: _________________________________________________ Group Code: ________________
New Name of Applicant Company: ________________________________________ NAIC No. _________________
New Group Name:
Group Code: ________________
Effective Date of Redomestication:
Previous State:
New State: _____________
Effective Date of Name Change:
Effective Date of Merger: ___________________________
Effective Date of Change of City within the State of Domicile: _______________________________________________
Effective Date of Change of Control of Foreign Insurer: _______________ Group Code: Previous_________ New_______
Previous Home Office Address: ______________________________________________________________________
______________________________________________________________________________________________
New Home Office Address: _________________________________________________________________________
______________________________________________________________________________________________
Previous Administrative Office Address: _______________________________________________________________
______________________________________________________________________________________________
New Administrative Office Address: __________________________________________________________________
______________________________________________________________________________________________
Previous Mailing Address: __________________________________________________________________________
______________________________________________________________________________________________
New Mailing Address: _____________________________________________________________________________
______________________________________________________________________________________________
Previous Phone: ____________________________
Fax: ___________________________________________
New Phone: _______________________________
Fax: ___________________________________________
Has the Applicant Company’s designee to appoint and remove agents changed as a result of this corporate amendment?
Yes
No
If yes, please note the new designee (name natural persons only): ________________________________________
If a merger of two or more foreign insurers:
Current Name of Surviving Applicant Company:
NAIC No.:
Group Code: ________
Proposed New Name of Surviving Applicant Company:
NAIC No.:
Group Code: ________
Name of Non-Surviving Insurer:
NAIC No.:
Group Code: ________
Name of Surviving Insurer:
NAIC No.:
Group Code: ________
Revised 12/19/14
2016 National Association of Insurance Commissioners
2
FORM 2C
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