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Insurer Filing Forms

The forms listed below can be printed and mailed to the California Department of Insurance (CDI) with a cover letter and the appropriate fee at the following address:

Accounting Services Bureau
State of California Department of Insurance
300 Capitol Mall
Sacramento, CA 95814

The California List of Approved Surplus Line Insurers (LASLI) Filing Requirements Guide has more details, including current fees and the required number of copies.

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Exhibit A: Verification for Regulatory Disclosure Statement

Insurers are required to submit a verified statement that discloses any currently known regulatory actions pending against the insurer or any affiliated entities for the current filing year. These regulatory actions include, but are not limited to, legal proceedings for receivership, conservation, liquidation, license revocation or suspension, or any other cease and desist order. If the insurer or its affiliate(s) is subject to such proceedings, the statement must identify the proceeding by date, jurisdiction, and relief or sanction sought. Copies of any outstanding orders must also be attached to the statement. {CIC §1765.2(c)(6)}

For insurers and their affiliates who are not subject to any currently known regulatory actions, the following is a specimen of such a verified regulatory disclosure statement that the Commissioner considers to be in compliance with the Code.



Exhibit B: Verification Statement

A "Verified Statement" is an originally signed statement that accompanies a document or copy, and is dated not more than 60 days before submission, from a responsible executive or official who has authority to provide the statement and knowledge whereof he or she speaks, attesting either under oath before a notary public, or under penalty of perjury under California law, that the assertions made in the document are true. {CIC §1760.1(q)}. The following is a specimen of such verified statement that the Commissioner considers to be in compliance with the Code.



Exhibit C: Verification [ Incorporating Previously Filed Documents ]

To incorporate a previously filed document(s) into a current annual renewal filing, the insurer must: (1) submit a verified statement that lists the document(s) previously provided to the CDI and affirm that there has been no change to the information contained in the previously filed document(s); and (2) make a specific reference to the prior filing(s) in its current annual renewal filing. The following is a specimen of such verified statement that the Commissioner considers to be in compliance with the Code.




Exhibit D: Verification [ When Certificate of Good Standing/Compliance Is Unavailable ]

If Certification of Good Standing/Compliance as required under CIC §1765.2(c)(2) is not available from the insurer’s domiciliary jurisdiction or any other state where it is licensed, the insurer must provide a verified statement signed by a responsible executive or officer of the company. The following is a specimen of such verified statement that the Commissioner considers to be in compliance with the Code.




Exhibit E: Checklist for U.S. Insurers

A checklist summary of the required documents to be filed annually.



Exhibit E: Checklist for Non-U.S. Insurers

A checklist summary of the required documents to be filed annually.



Exhibit F: Verification [For Documents Available From The NAIC Or Other Public Source]

Required documents available from the NAIC or other public source do not need to be filed with the CDI, nor do they need to be certified or verified. Instead, the insurer must submit a verified statement to the CDI identifying the document that is available from the NAIC or other public source along with the appropriate filing fee. The following is a specimen of such verified statement that the Commissioner considers to be in compliance with the Code.