logo

Company License Withdrawals

NEVADA FOREIGNS

Risk Purchasing Group Withdrawal Checklist - NV Form 473
Submit form and any attachments electronically to Kathy Lamb.

Risk Retention Group Withdrawal Checklist - NV Form 469
Submit form and attachments electronically to Kathy Lamb.

Statement of WithdrawalNAIC Form 17 Traditional Life or Health Company
This form should be used by a foreign insurance company to file for withdrawal/complete surrender of their Certificate of Authority.
Submit form and any attachments electronically to Robert Gallegos.

Affidavit of Lost Certificate of AuthorityNAIC Form 15
This form should be used when an applicant cannot find their most recent Certificate of Authority issued by the Nevada Division of Insurance.

NEVADA NON-CAPTIVE DOMESTICS

Statement of WithdrawalNAIC Form 17 Traditional Life or Health Company
This form should be used by a domestic insurance company to file for withdrawal/complete surrender of their Certificate of Authority.
Contact the Chief Insurance Examiner, Omar Akel, prior to the submission of any documents (775) 687-0743.
Submit form and attachments electronically to Robert Gallegos.

Affidavit of Lost Certificate of AuthorityNAIC Form 15
This form should be used when an applicant cannot locate their most recent Certificate of Authority issued by the Nevada Division of Insurance.

Nevada Division of Insurance
Corporate & Financial Affairs
1818 E. College Parkway, Suite 103
Carson City, NV 89701