Company License Withdrawals

Risk Purchasing Group Withdrawal Requirements

Risk Retention Group (foreign) Withdrawal Requirements

Statement of Voluntary Dissolution - Form 16a Instructions

Statement of Voluntary Dissolution (Company) - Form 16a

This form should be completed by those reporting entities that are ending their existence in all states. The form is to be submitted to the domicile state when requesting dissolution or cancellation of the Certificate of Authority and may also be requested by non-domiciliary states when requesting cancellation of the foreign Certificate of Authority. The purpose of the form is to provide information about the status of all foreign Certificates of Authority and any obligations that are still present in those states.

Statement of Voluntary Dissolution (RRG) - Form 16b

This statement is submitted to the Risk Retention Group's domestic state regulator to summarize how the Risk Retention Group has addressed its registration in other states. Limit the information to those states in which a registration has been held within the last 10 years.

Statement of Withdrawal - Form 17

Affidavit of Lost Certificate of Authority

Submit documents electronically to:

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