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Domestic Insurance Company Withdrawal (Form 16)
Domestic Insurance Company Withdrawal (Form 16)

Last Updated: 07/19/2024
Updates to the information will be noted with a “ * ” next to the state name and edits will be italicized and bolded.

State Fee Requirement Contact
AL No Fee Signed and Notarized Affidavit from Company President stating that all claims and/or liabilities related to claims have been paid. Original COA must be returned.

Hamp Russell

*AK N/A Completion of Voluntary Surrender of Certificate of Authority (Form 08-290).  Additional requirements in AS 21.10.135, AS 21.06.245, AS 21.69.648.

Kevin Richard

AZ None Contact the Department for instructions.

Cary W. Cook
Assistant Financial Compliance Officer

AR None

Any insurer desiring to surrender its Certificate of Authority, withdraw from this state, or discontinue the writing of certain classes of insurance in this state shall give ninety (90) days notice in writing to the State Insurance Department and shall state in writing its reasons for such action. The commissioner may waive any part of the notice requirement.  A.C.A §23-63-211(e)

Return the original certificate of authority or an affidavit of loss notarized and signed by an officer of the company.

Provide a notarized affidavit by an officer of the Company stating there are no outstanding policies, claims or known liabilities, and the Company has no premium tax (or other taxes) due in this state.

Contact our Accounting Division for the filing of the proper “final” tax filings. Accounting Division (501-371-2605).

Legal Division

CA $ 1551 + $1000 publication fee

State specific forms required - Withdrawal from California as an Insurer.
CO None Colorado Domestic Dissolution Guidelines

CT None

Provide Form 16 along with verification that there are no active policies being written.

Company Licensing Section
(860) 297-3800

  • Completed NAIC UCAA Statement of Dissolution (Form 16).
  • Provide a statement notarized by an officer of the company that there are no outstanding policies, claims and liabilities.
  • Return original Certificate of Authority.

Delaware Department of Insurance
Attn. B.E.R.G
1351 West North Street, Suite 101
Dover, DE 19904
(302) 674-7300

DC No charge Provide a written statement that the insurer is surrendering the license. Complete Corp Amendment Application Form 17.

Kathy Alexander
(202) 442-7819

*FL   Florida does not use this Form.  
GA Contact state Letter requesting to withdraw, UCAA Form 16a, affidavit stating the company has no outstanding claims, suits, judgements or policies in the state of Georgia.

Scott Sanders

HI Contact state  


ID None 

IL None 50 Illinois Administrative Code Part 2410.
IN $25

IC 27-1-10. UCAA Form 16a.

Annette Gunter
(317) 232-2428

IA Contact Iowa Insurance Division

Contact Iowa Insurance Division.

KS None

Written statement from the Company stating that there is no existing or run-off business in KS and they do not intend to transact business in KS in the future.

Uniform Certificate of Authority Application (UCAA) Statement of Withdrawal (UCAA Form 17).

Tish Becker
Director, Financial Surveillance Division
Kansas Insurance Dept.
Financial Surveillance Division
1300 SW Arrowhead Road
Topeka, KS 66604
(785) 296-7816
KY Contact state    
LA None

Application for Withdrawal found on website at

Tangela Byrd
Insurance Manager
Louisiana Department of Insurance
1702 North 3rd Street (70802)
P.O. Box 94214
Baton Rouge, LA 70804-9214

ME Contact state    
MD None

Company will need to furnish the current Maryland original Certificate of Authority.

In addition, a cover letter requesting the Company’s intention to withdraw, signed by an appropriate Corporate officer.

Erin Nickles
Director of Company Licensing & Premium Tax Auditing
Maryland Insurance Administration
200 St. Paul Place, Suite 2700
Baltimore, MD 21201
(410) 468-2451 (Office)

MA Contact state    
MI No fee

Company should submit letter indicating its intent to surrender and return its original certificate of authority.                                                                                          
An affidavit signed by an actuary must be included indicating that the Company does not have any outstanding Michigan business to secure.  

Linda Martin
Application Coordinator


Contact state department for requirements at


Surrender Current Certificate of Authority. All taxes, fees & filings due to MS Department of Revenue, MS State Rating Bureau, MS Workers’ Comp.
Commission & MS Insurance Department have been made. If business has been transferred to another company prior to the filing of the Form 17, prior notice of the reinsurance transaction and approval of the policyholder notification would be required. Actuarial statement as to there being any outstanding liabilities. Draft Articles of Dissolution for approval. Board and Shareholders Resolutions approving the dissolution.

Chad Bridges

MO $150

Requirements vary based on circumstances.

Debbie Doggett 

MT   Contact Montana CSI (406) 444-2040.  
NE $0 Contact DOI.
NV Contact state    
NH None

If you have any liabilities they must be liquidated (or reinsured). File your articles of dissolution with the secretary of state.


Orderly withdrawal of insurance business N.J.A.C. 11:2-29.1. Contact state for requirements.

Nakia Reid, Manager
(609) 940-7613         
NM No Fee

Surrender Certificate of Authority.

NAIC UCAA Statement of Withdrawal Form 17.

Victoria A. Baca
Licensing Director
(505) 827-4554

Ursula Almada
Company Licensing Bureau
(505) 827-4524

NY No Fee For Life companies: submit Reg. 109 plan, certified board resolution, surrender license. Redomestication not allowed. Life Contact Bradley Rice at OGC (
NY No Fee Health: At least forty-five days prior to such proposed action insurer must submit a plan to protect the interests of people of NY for prior approval by the Superintendent pursuant to §1105 of the New York Insurance Law and Department Regulation 109 (11 NYCRR 88).

We require that one original document be sent to: Office of General Counsel State of New York Department of Financial Services
One Commerce Plaza
Albany, NY 12257
(518) 474-6623

And another original to the applicable bureau:

Health Bureau
Tom Dudek, Supervising Examiner
New York State Department of Financial Services
One State Street
New York, NY 10004
(212) 480-5037

NC Contact state  


ND None

See requirements on Department's website:…

Matt Fischer
Chief Examiner & Director of Company Licensing & Examinations

OH None Company must file surrender of certificate of authority.

Cameron Piatt
Assistant Chief-Taxes, Admissions and Foreign Analysis
Office of Risk Assessment
(614) 728-1074

OK Contact state    
OR Contact state  



Please review guidance at:….

PR No Fee

Comply with Sections 29.480 to 29.540 of The Puerto Rico Insurance Code.

Glorimar Santiago

RI None Request withdrawal. If approved, an Order is issued by the Superintendent of Insurance. Debra Almeida
Rhode Island Insurance Division
1511 Pontiac Avenue, Bldg 69-2
Cranston, RI 02920
(401) 462-9542
SC None

A letter from the President or CEO stating there are no outstanding policies in-force and no outstanding liabilities or claims. Any policy in-force or unsatisfied claims outstanding in SC is provided via Reinsurance or Merger by a SC authorized entity.

See Code Section 38-61-80 Withdrawing from the market.

If the company has policies in force - The insurer would need to submit a SERFF filing formally withdrawing all forms, rates, and rules that have been approved by our Department, as they are no longer considered valid if they leave our state.

Ryan Basnett
Chief Financial Analyst
(803) 737-6114


SD Contact state



$90 fee if planning to maintain the license

If redomesticate out to other state:

  1. A letter signed by the President/CEO indicating the intention to redomesticate.
  2. Copy of the approval granted by a new domiciliary state regulator.
  3. Amended Articles of Incorporation/Reorganization/Redomestication, certified by a new domiciliary state regulator.
  4. Certificate of Compliance issued by a new domiciliary state regulator.
  5. Certificate of Deposit issued by a new domiciliary state regulator.

The original Certificate of Authority issued to the Company by the TDCI, or an Affidavit of Lost or Misplaced Certificate.

Trey Hancock
Hui Wattanaskolpant (

TX $0 UCAA Form 16A (Statement of Voluntary Dissolution form) and TX Form FIN351 (Voluntary Dissolution Checklist).

Filings -

UT Contact State    
VT $100 Approval required by the Commissioner and once approved proof of redomestication is filed with the Secretary of State. 8 V.S.A. §3438

802-828-2470 or

VA None An officer of the company must submit an affidavit requesting to surrender its license and the company is reviewed for direct business in Virginia.

Connie Duong

WA No fee

Return of the original Certificate of Authority. Documentation that supports the transfer or assumption of any in-force business. RCW 48.05.290

Company Supervision Division
Washington State Office of the
Insurance Commissioner
PO Box 40255
Olympia, WA 98504-0255
(360) 725-7200

WV No fee

45 days prior, the company is required to submit a formal plan of withdrawal.

WV Offices of the Insurance Commissioner
Financial Conditions Division
PO Box 50540
Charleston, WV  25305-0540
(304) 558-2100

WI No fee    

If leaving the health market, the company must comply with W.S. 26-15-121 and W.S. 26-19-305. If leaving the property & casualty market, the company must comply with Chapter 35 of the Wyoming Insurance Code. The company must return the original Certificate of Authority. W.S.26-3-113(c).

G. Douglas Melvin, Chief Examiner
Wyoming Ins. Dept.
106 East 6th Avenue
Cheyenne, WY 82002
(307) 777-5619