Withdrawal of Company License

NEVADA FOREIGNS

Please submit forms and any attachments electronically to Finances@doi.nv.gov 

Risk Purchasing Group Withdrawal Checklist - NV Form 473

Risk Retention Group Withdrawal Checklist - NV Form 469

Statement of Withdrawal – NAIC 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.

Affidavit of Lost Certificate of Authority – NAIC 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 Withdrawal – NAIC 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.

Affidavit of Lost Certificate of Authority – NAIC 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