Certificate Of Redomestication Form - Office Of The Secretary Of The State

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CERTIFICATE OF REDOMESTICATION
INSURANCE COMPANY REDOMESTICATION FROM CONNECTICUT
Office of the Secretary of the State
MAILING ADDRESS:
DELIVERY ADDRESS:
Commercial Recording Division
Commercial Recording Division
Connecticut Secretary of the State
Connecticut Secretary of the State
P.O. Box 150470
30 Trinity Street
Hartford, CT 06115-0470
Hartford, CT 06106
860-509-6003
860-509-6003
FEE: $100.00
Make Checks Payable To “Secretary of the State”
Space For Office Use Only
1. NAME OF CONNECTICUT INSURANCE COMPANY:
2. STATE TO WHICH THE INSURANCE COMPANY IS REDOMESTICATING: ___________________________
3. APPROVALS:
The corporation's redomestication was approved by the Insurance Commissioner of the State of Connecticut as
demonstrated by such Commissioner's Certificate of Approval included herewith.
The corporation's redomestication from Connecticut was further approved by the Insurance Commissioner of the State of
____________________________________________.
(State to which corporation is redomesticating)
4. VOTE INFORMATION: (check and complete A. or B.)
_____A.
The insurance company has authority to issue capital stock. The resolution of redomestication was adopted
by its board of directors and approved by its shareholders as follows (provide at minimum the total number
of shareholder votes cast in favor of the resolution and the total number of votes cast against the resolution
or, if no shareholder approval was required, provide a statement to that effect):
_____B.
The corporation is a mutual insurance company. The resolution of redomestication was adopted by its
board of directors and approved by its members as follows (provide at minimum the total number of
member votes cast in favor of the resolution and the total number of votes cast against the resolution or, if
no membership approval was required, provide a statement to that effect):
5. EXECUTION:
Signed this_____________day of _____________________________, 20_______.
Print or type name of signatory
Capacity of signatory
Signature
REV. 12/07/09

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