Alabama Insurance Department
P. O. Box 303351
Montgomery, AL  36130

Kevin Richard
Kevin.richard@alaska.gov

• Provide a statement of the insurer’s financial condition as of a date within 60 days of the
  filing date of the request for termination that includes a written statement, signed by two officers of the insurer as authorized on the jurat page of the insurer’s most recent annual statement, verifying that the statement of financial condition reflects the insurer’s financial position as of the date signed.
• Provide a plan of extinguishment of the insurer’s outstanding liabilities that satisfies the requirements of AACR20-6-303(C) OR a sworn affidavit stating that the insurer has no outstanding liabilities to policyholders or claimants under AAC R20-6-303 (C).
• Arizona Administrative Code R20-6-303

Cary W. Cook
Assistant Financial Compliance Officer
Arizona Department of Insurance and Financial Institutions
Financial Affairs Division
100 N. 15^th Ave., Suite 261
Phoenix, AZ 85007-2630
(602) 364-3986
cary.cook@difi.az.gov

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 Arkansas 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
Insurance.legal@arkansas.gov

State specific forms required - Withdrawal from California as an Insurer

Cindy Hathaway
Director, Corporate Affairs
(303) 894-7836
Cindy.Hathaway@state.co.us

• All outstanding losses and liabilities have been paid in the State of Connecticut.
• Board of Directors Resolution and Shareholder Resolution.
• Completed NAIC UCAA Statement of Withdrawal (Form 17)

Company Licensing Section
(860) 297-3800
cid.financial@ct.gov

• Completed NAIC UCAA Statement of Withdrawal (Form 17)
• 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 
berg@delaware.gov

• Return Original Certificate of Authority.
• Provide a written statement that the insurer is surrendering the license.                                                                                              

Kathy Alexander
Company Licensing Specialist
DC Department of Insurance, Securities and Banking 
1050 First St., NE, Suite 801
Washington, DC 20002
(202) 442-7819
kathy.alexander@dc.gov

• 90 days written notice of reason for surrendering. Refer to Section 624.430, Florida Statutes, and
  Rule 690-141.020, Florida Administrative Code for the required format for the Notice and its contents.
• Return original Certificate of Authority.

For all Life & Health Companies:
Joe Erhart
Applications Coordinator – L&H
(850) 413-5066
joe.erhart@floir.com

For all Property & Casualty Companies:
Katherine Schwalb
Management Review Specialist – P&C
(850) 413-2405
katherine.schwalb@floir.com

• Complete UCAA Form 17
• Return original Certificate of Authority

Keyatta Kelly
regservices@oci.ga.gov

Return of the company’s original Hawaii Certificate of Authority or an affidavit of loss (Form 15) notarized
and signed by an officer of the company. 

Comply with the following Hawaii Revised Statute (HRS) sections:

HRS §431:3-215:  Withdrawal from State; obligation
HRS §431P-17:  Additional notice requirement

Andrew Chow
Insurance Examiner
State of Hawaii, Insurance Division
P.O. Box 3614
Honolulu, HI 96811-3614
Tel. (808) 586-3874
Fax: (808) 586-3873
achow@dcca.hawaii.gov

• Form 17 or letter requesting to withdraw.
• Return Original Certificate of Authority.

Corporate Amendment Apps:
Candice Pratt
Technical Records Specialist
Idaho Dept. of Insurance
700 W. State Street, 3rd Floor
PO Box 83720
Boise, ID 83720-0043
Tel: (208) 334-4311
candice.pratt@doi.idaho.gov 

• Letter requesting withdrawal and completion of Form 17, Statement of Withdrawal
• Return of the original Indiana Certificate of Authority for cancellation

Annette Gunter
Indiana Department of Insurance
(317) 232-2428
agunter@idoi.in.gov

Return Original Certificate of Authority. Letter requesting withdrawal and completion of Form 17, Statement of Withdrawal.

Dana Sanders
Iowa Insurance Division
1963 Bell Avenue, Suite 100
Des Moines, IA 50315
company.licensing@iid.iowa.gov

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).

Return the company’s original Kansas Certificate of Authority or submit an Affidavit of Lost Certificate of Authority (UCAA Form 15).

Tish Becker
Director, Financial Surveillance Division
Kansas Insurance Dept.
Financial Surveillance Division
1300 SW Arrowhead Road
Topeka, KS 66604
(785) 296-7816
Tish.becker@ks.gov

A letter stating the Co. has no business in KY.
Return of Original Certificate of Authority.
Company must also file Articles of Dissolution with the KY Secretary of State.

KRS 304.3-180

Kentucky Department of Insurance
P. O. Box 517
Frankfort, KY 40602-0517
Gina Metts
Financial Standards and Examination Division
(502) 782-5298
gina.metts@ky.gov

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

24-A M.R.S.A.§ 415-A: Withdrawal plan must be submitted for approval at least 60 days prior to the
proposed date of withdrawal. See section 415-A and Me. Dep’t of Prof. & Fin. Reg., 02-031 CMR 400
for plan requirements.

The original Certificate of Authority must be returned.

Lauri Cooper
Maine Bureau of Insurance
34 State House Station
Augusta, ME 04333-0034
(207) 624-8464
laurelyn.s.cooper@maine.gov

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)
erin.nickles@maryland.gov

M.G.L.c.175,§44 is for MA Domestic Insurers.

Foreign Insurers need to demonstrate that there is a plan in place that has been approved that protects
MA policyholders with current or future claims.

MA Division of Insurance
Jack Baglio
Financial Surveillance & Company Licensing
1000 Washington Street, Suite 810
Boston, MA 02118-6200
(617) 521-7394
john.baglio@state.ma.us

In addition to the UCAA corporate amendments application, an affidavit signed by an actuary must be
included indicating that the Company does not have any outstanding Michigan business to secure.  

Return of original Certificate of Authority.

Linda Martin
Application Coordinator
517-284-8756
martinl@michigan.gov

If the Company hasn’t written in MN: the Company is automatically allowed to withdrawal.

60A.052, subd. 4a

The Department requires a letter, signed by the President of the Company, to be sent to us stating the
number and amount of outstanding claims and number of policies in-force in the State of Minnesota.  The letter must also state that the Company will pay any and all outstanding desk audit fees charged to the Company at the time of the withdrawal.  The Department will review the information and may issue an Order permitting such withdrawal from Minnesota.  Note under Minn. Stat. 60A.052, Subd. 4a, all direct liability to Minnesota policyholders and obligees have to be assumed by another insurer before a company is allowed to withdraw.

Company Licensing 
companylic.commerce@state.mn.us

Contact – Kathleen Orth
Chief Examiner/Solvency Manager
MN Dept. of Commerce
85 7th Place East, Suite 280
St. Paul, MN  55101-2198

Surrender current Certificate of Authority

Form 12 would not be required to be filed by an unlicensed insurer.

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.

Original signatures are needed on Form 17.

David Browning
Director of Financial & Market Regulation
P.O. Box 79
Jackson, MS 39205
601-359-9218
david.browning@mid.ms.gov

375.871.1 RSMO
Copy of Board of Director’s Resolution regarding withdrawal from the State.  The Department will verify that business has been transferred to another licensed company and the insurer has no outstanding taxes or fees in Missouri. 

Kelly Hopper
(573) 751-2711

Contact Montana CSI

Tavin Mogus
tmogus@mt.gov
(406) 444-3496

• The company must have a procedure in place to handle outstanding claims and policyholders for any
  in-force business.
• Surrender current Certificate of Authority.

Kristy Hadden, Company Administrator
(402) 471-0373
Kristy.hadden@nebraska.gov

Lori Bruss, Staff Assistant II
Examination Division
(402) 471-4045
lori.bruss@nebraska.gov

Foreign RRG –
Surrender original Nevada Certificate of Authority or submit a Form 15 Affidavit of Loss, signed by
President of company.
Contact Company Licensing, to obtain a Foreign RRG Withdrawal Requirements Checklist

Foreign Insurance Company –
Surrender original Nevada Certificate of Authority or submit a Form 15 Affidavit of Loss, signed by
President of company.
Submit Form 17 Statement of Withdrawal to Company Licensing. 

Nevada Division of Insurance
Company Licensing
finances@doi.nv.gov
(775) 687-0700

NH Application for Amendment Form

Original Certificate of Compliance from state of domicile

Return of NH current original Certificate of Authority

Linda Zalinskie, Financial Regulation Division
NH Insurance Dept.
21 S Fruit St., Ste 14
Concord, NH 03301
Tele (603) 271-2528
Linda.m.zalinskie@ins.nh.gov

If a company has no open liabilities in New Jersey for the lines it wishes to withdraw, it may submit a
certification to that effect from its Board of Directors to:
New Jersey Department of Banking and Insurance
Solvency Regulation - Nakia Reid
P.O. Box 325
Trenton, NJ 08625

If a company has open liabilities, it must submit a withdrawal plan pursuant to N.J.A.C. 11:2-29.1 et seq.
to the address noted above.

Surrender Certificate of Authority.

NAIC UCAA Statement of Withdrawal Form 17

Victoria Baca
(505) 827-4554
Victoriaa.Baca@osi.nm.gov

Ursula Almada
(505) 827-4524
Ursula.Almada@osi.nm.gov

Office of Superintendent of Insurance
PO Box 1689
Santa Fe, NM 87504-1689

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:Property Bureau
Eileen Fox, Assistant Chief Examiner
New York State Department of Financial Services
One State Street
New York, NY 10004
(212) 480-5565
eileen.fox@dfs.ny.gov

Life Bureau
Victor Agbu, Assistant Chief Examiner
New York State Department of Financial Services
One State Street
New York, NY 10004
(212) 480-5040
victor.agbu@dfs.ny.gov

Health Bureau
Warren Youngs, Supervising Examiner
New York State Department of Financial Services
One State Street
New York, NY 10004
(212) 480-5045 warren.youngs@dfs.ny.gov

Tom Dudek, Supervising Examiner
New York State Department of Financial Services
One State Street
New York, NY 10004
(212) 480-5037
Thomas.Dudek@dfs.ny.gov

Cease writing business in NC.
Provide actuarial Certification regarding outstanding policyholders obligations. 

Joe Greene
1203 Mail Service Center
Raleigh, NC 27699-1203
(919) 807-6182
joseph.greene@ncdoi.gov

For Property & Casualty products pursuant to ND.
N.D.C.C. Section 26.1-25-04.4

See http://www.nd.gov/ndins/companies/companylicensing/voluntarywithdrawal/ for voluntary withdrawal guidelines for all companies.

Company Licensing and Examinations Divisions
ND Insurance Department
600 East Boulevard Avenue, Dept 401
Bismarck, ND 58505-0320
(701) 328-2440
colicexam@nd.gov

Cameron Piatt
Assistant Chief-Taxes, Admissions and Foreign Analysis
Office of Risk Assessment
(614) 728-1074
Cameron.piatt@insurance.ohio.gov

Return Oklahoma Certificate of Authority, completed UCAA Form 17 Statement of Withdrawal and UCAA
Form 16a (if applicable).

Please assure rate and form filings have been completed electronically through SERFF. Call our Rate &
Form Compliance Division at 405-521-3681 should you have any questions regarding rate and form filings.
Pursuant to Oklahoma Regulation 365:15-1-18/Oklahoma Regulation 365: 15-7-31. Any insurer desiring
to withdraw from the state or discontinue the writing of certain classes of insurance in this state shall give
ninety (90) days’ notice in writing to the Insurance Department and shall state in writing its reasons for
such action.

The insurer shall also provide the following information: 
(1) The number of policyholders effected; 
(2) The number of insurance agents effected; 
(3) The date the insurer will cease writing new business; 
(4) The date the insurer will start non-renewing insurance policies; 
(5) The date the insurer will transfer policyholders; 
(6) Whether the insurer has made arrangements with another insurer to pick up the renewals; 
(7) The lines of insurance on which the insurer plans to concentrate; and 
(8) Whether the insurer anticipates re-entering the market.

Kayla Lowe-Whitlow
Financial Specialist
Oklahoma Insurance Department
400 NE 50^th Street
Oklahoma City, OK 73105
(405) 521-6607
ucaa@oid.ok.gov

Submit an affidavit, which indicates the company, has no outstanding claims, liabilities or in-force business
in the state of Oregon and if any should arise, the company will take full responsibility. Affidavit must be
signed by an officer of the company. Submit current original Certificate of Compliance from state of domicile.
Return original Certificate of Authority.

ORS 731-512

Insurance Institutions
Insurance Division-4
Company Regulation Section
350 Winter St., NE Room 440
Salem, OR 97301-3883
(503) 947-7982
Web.Inscomp@dcbs.oregon.gov

Please review guidance at https://www.insurance.pa.gov/Companies/PlanOfWithdrawal/Pages/default.a…

RA-insresponse@pa.gov

Circular letter No. E-10-1395-95 found on our website.

Companies intending to surrender should contact the Department for guidance on how to proceed.

Mrs. Glorimar Santiago
Director
Admissions and Financial Analysis Division
(787)304-8686 Ext 4401
gsantiago@ocs.pr.gov

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
rbasnett@doi.sc.gov

Submit written letter of request to withdraw, signed by an officer.
Indicate: No policies currently in force in SD & no outstanding claims or liabilities.
Please state: No business done in calendar year or if Yes premiums were received in calendar year. If Yes a "Final Premium Tax Return must be submitted along with taxes.
Mark as Final Return.
Return Original Certificate of Authority

Patsy Madsen, Company Licensing Specialist
SD Division of Insurance
124 S. Euclid Ave., 2^nd Floor
Pierre, SD 57501
(605) 773-3563
patsy.madsen@state.sd.us

A statement advising of the resolution of the company’s current business in TN.

Phil Adams, Analyst
(615) 741-1670
phil.adams@tn.gov

Company Licensing and Registration
General Inquiries:
CompanyLicense@tdi.texas.gov

Electronic Filing via UCAA or CLRFilings@tdi.texas.gov

UCA § 31A-4-115

Statutes, Administrative Rules, and forms are available at https://insurance.utah.gov

Email documentation to company-renewals@utah.gov 

Company Licensing
(802) 828-2470
dfr.complic@vermont.gov

Gayle Henderson, Office Supervisor
VA SCC/Bureau of Insurance
P.O. Box 1157
Richmond, VA 23218
(804) 371-9869
gayle.henderson@scc.virginia.gov

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
clc@oic.wa.gov

https://www.wvinsurance.gov/company-definitions

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
oicfinancialconditions@wv.gov

Any transfer of business or reinsurance other than in the normal and usual course of business must be reported to the Office not less than 30 days in advance of the proposed effective date, and is subject to disapproval under s. 618.32, Wis. Stat.

If applying for a release from regulation, the company must comply with s. 618.36, Wis. Stat.

Mark McNabb
Division of Financial Regulation
Office of the Commissioner of Insurance
(608) 266-8854
mark.mcnabb@wisconsin.gov

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 6^th Avenue
Cheyenne, WY 82002
(307) 777-5619
doug.melvin@wyo.gov