Form Rdom-1 - Statement Of Redomestication (California Insurer Only) Page 5
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5RDOM-1
Secretary of State
Statement of Redomestication
(California Insurer Only)
IMPORTANT —
Read Instructions
before completing this form.
Must be submitted with a certificate of authority issued by the
California Insurance Commissioner.
See Instructions.
There is No Fee for filing a Statement of Redomestication
Copy Fees – First page $1.00; each attachment page $0.50;
Certification Fee - $5.00 plus copy fees
Above Space For Office Use Only
Redomesticating Entity Information
1. Redomesticating Entity Name
2. 7-Digit Secretary of State Entity (File) Number
(Enter the exact
corporation name on file with the Secretary of State.)
3. The redomesticating insurer is authorized to carry out the redomestication under California law and the
jurisdiction to which the insurer is redomesticating.
4. The redomesticating insurer has complied with the requirements to redomesticate as required by California
law and the jurisdiction to which the insurer is redomesticating.
5. The Insurance Commissioner has approved the redomestication of the insurer and a copy of the amended
certificate of authority, evidencing the approval of the Insurance Commissioner, is attached to this statement
of redomestication.
Redomesticated Entity Information
6. Redomesticated (Foreign) Entity Name
7. Jurisdiction
(Enter the
(Enter the new state of domicile.)
name that the entity will use in the foreign jurisdiction.)
8. Name and street address in the foreign jurisdiction of the redomesticated insurer’s agent for service
of process
a. Agent’s First Name / Entity Name
Middle Name
Last Name
Suffix
b. Street Address
City (no abbreviations)
State
Zip Code
Signature
The information is true and correct and I am authorized to sign on behalf of the corporation.
__________________________________________________________
____________________________________________________
Signature
Type or Print Name
2018 California Secretary of State
RDOM-1 (EST 01/2018)
Clear Form
Print Form
bizfile.sos.ca.gov
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