Form 2c - Uniform Certificate Of Authority Application (Page 3 of 4) in pdf

Applicant Company Name: _____________________________

NAIC No. _________________________

FEIN:

_________________________

Surviving Applicant Company’s Home Office Address: ____________________________________________________

______________________________________________________________________________________________

Surviving Applicant Company’s Administrative Office Address: _____________________________________________

______________________________________________________________________________________________

Surviving Applicant Company’s Mailing Address: ________________________________________________________

______________________________________________________________________________________________

Surviving Applicant Company’s Telephone:

Fax:______________________________

Are these addresses the same as those shown on the Applicant Company’s Annual Statement?

Yes

If not, indicate why: _________________________________________________________________________

If this application represents a name change, did the Applicant Company experience a merger or an owner change prior to the

name change?

Yes

If yes, please be sure an application is also submitted for the merger and/or ownership change transaction.

Date of Last Market Conduct Examination: _____________________________________________________________

Has the Applicant Company had an application for these lines of business refused by this or any other state prior to the date

of this application?

Yes

If yes, give full explanation in an attached letter.

The following information is required of the individual (Applicant Company employee or paid consultant) who is authorized

to represent the Applicant Company before the department.

Name: _________________________________________________________________________________________

Title: __________________________________________________________________________________________

Mailing Address: _________________________________________________________________________________

E-Mail Address: _____________________

Phone: ___________________

Fax: ____________________________

Please provide a listing of all other applications filed by the Applicant Company, or any of its affiliates, which are pending

before the Department:

______________________________________________________________________________________________

A Certificate of Compliance from the Applicant Company's state of domicile (for foreign applicants) and the Applicant

Company's original Certificate of Authority or an Affidavit of Lost Certificate of Authority must accompany this application.

(not applicable for Change of Control, Amended Articles of Incorporation or Amended Bylaws.)

Revised 12/19/14

 2016 National Association of Insurance Commissioners

FORM 2C

Form 2c - Uniform Certificate Of Authority Application Page 3