Foreign Withdrawal Requirements (Form 17)

FOREIGN INSURANCE COMPANY WITHDRAWAL/COMPLETE SURRENDER OF CERTIFICATE OF AUTHORITY APPLICATION

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		Surrender current Alabama Certificate of Authority UCAA Form 17, along with attachments which are required based on the responses to the Form, must be filed.	Alabama Insurance Department P. O. Box 303351 Montgomery, AL 36130
AK	N/A	Completion of Voluntary Surrender of Certificate of Authority (Form 08-290). Other requirements in AS 21.09.135, AS 21.09.245.	Kevin Richard Kevin.richard@alaska.gov
AZ	None	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
AR	No	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
CA	$1551 + $1000 (publication fee)	State specific forms required - .	CAB-SF-Intake@insurance.ca.gov
CO	None	Summary of the company’s plan to transfer or run-off any existing business in the lines to be deleted.	Cindy Hathaway Director, Corporate Affairs (303) 894-7836 Cindy.Hathaway@state.co.us
CT	None	All outstanding losses and liabilities have been paid in the State of Connecticut. Board of Directors Resolution and Shareholder Resolution. Completed ��о��ٷ� UCAA Statement of Withdrawal (Form 17).	Company Licensing Section (860) 297-3800 cid.financial@ct.gov
DE		Completed ��о��ٷ� 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
DC		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
*FL	None	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 Applications Coordinator – P&C (850) 413-2405 katherine.schwalb@floir.com
GA	Filing Fee - $75 Processing Fee - $5	Complete UCAA Form 17. Return original Certificate of Authority.	Keyatta Kelly regservices@oci.ga.gov
HI	None	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
ID	None	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
IL	$50	215 IICS 5/118 of the Illinois Insurance Code. Submit letter to Department requesting withdrawal. Submit UCAA Form 17, Statement of Withdrawal. Return of the original Illinois Certificate of Authority for cancellation.	Marcy Savage Deputy Director, Corporate Regulation Section Illinois Department of Insurance 320 West Washington Street, 4th Floor Springfield, IL 62767 marcy.savage@illinois.gov
IN		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
IA	Fees are retaliatory	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
KS		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 Tish.becker@ks.gov
KY		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
LA	None	La. R.S. 22:341 UCAA Form 17 Statement of Withdrawal and UCAA Statement of withdrawal Louisiana Specific Addendum. Return of the original Certificate of Authority.	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
ME		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
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) erin.nickles@maryland.gov
MA		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
MI		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
MN		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
*MS		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.	Chad T. Bridges Director of Financial & Market Regulation P.O. Box 79 Jackson, MS 39205 601-359-2136 Chad.Bridges@mid.ms.gov
MO	$150	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
MT		Contact Montana CSI.	Tavin Mogus tmogus@mt.gov (406) 444-3496
NE	$0	Submit UCAA form 17. The company must have a procedure in place to handle outstanding claims and policyholders for any in-force business. Surrender current Certificate of Authority.	Doi.companylicensing@nebraska.go
NV		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	$25 and subject to retaliatory fees.	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
NJ		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.	Nakia Reid, Manager (609) 940-7613 Nakia.Reid@dobi.nj.gov
NM	No Fee	Surrender Certificate of Authority. ��о��ٷ� 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
NY		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: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 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
NC	None	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
ND	None	For Property & Casualty products pursuant to ND. N.D.C.C. Section 26.1-25-04.4. See 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
OH	None	In order to surrender its COA, a company must provide notice to policyholders through publication and then make application to the Department to surrender. Companies intending to surrender should contact the Department for guidance on how to proceed.	Cameron Piatt Assistant Chief-Taxes, Admissions and Foreign Analysis Office of Risk Assessment (614) 728-1074 Cameron.piatt@insurance.ohio.gov
OK		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
OR	None	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
PA		Please review guidance at:	RA-insresponse@pa.gov
PR		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
RI	None	Request withdrawal.	Debra Almeida Rhode Island Insurance Division 1511 Pontiac Avenue, Bldg 69-2 Cranston, RI 02920 (401) 462-9542 debra.almeida@dbr.ri.gov
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 rbasnett@doi.sc.gov
SD		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
TN	None	A statement advising of the resolution of the company’s current business in TN.	Phil Adams, Analyst (615) 741-1670 phil.adams@tn.gov
TX	$0	Cancellation of certificate of authority filings only. A market withdrawal plan filing as required in Texas Insurance Code (TIC) 827 and 28 Texas Administrative Code (TAC) §§7.1801-7.1808 provides for a company to withdraw with PRIOR approval of the Commissioner of Insurance. See webpage for withdrawal requirements: .	Company Licensing and Registration General Inquiries: CompanyLicense@tdi.texas.gov Electronic Filing via UCAA or CLRFilings@tdi.texas.gov
*UT	Withdrawal Fee, if required by UCA § 31A-4-115(2)	UCA § 31A-4-115. Statutes, Administrative Rules, and forms are available at .	Email documentation to company-renewals@utah.gov
VT	$25.00 or retaliatory amount	A foreign or alien company, upon withdrawing from the state of Vermont, shall pay to the Commissioner $25.00 for the filing of its final financial statement. 8 V.S.A § 3561	Company Licensing (802) 828-2470 dfr.complic@vermont.gov
VA	None	A foreign insurance company/corporation is referred to the Office of the Clerk of the State Corporation Commission to surrender its general certificate of authority. An officer of the company must submit an affidavit requesting to surrender its license and the company is reviewed for direct business in VA.	Gayle Henderson, Office Supervisor VA SCC/Bureau of Insurance P.O. Box 1157 Richmond, VA 23218 (804) 371-9869 gayle.henderson@scc.virginia.gov
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 clc@oic.wa.gov
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 oicfinancialconditions@wv.gov
WI	No fee	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
WY		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

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