California Code of Regulations › Title 10 - Investment › Chapter 5 - Insurance Commissioner › Subchapter 3 - Insurers › Article 1.3 - Standards for Approval of Insurer Names › Section 2278.59 - Form N-1

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
REQUEST FOR NAME APPROVAL AND
					 RESERVATION
(FORM N-1)
To
: Name Reservation Unit
Legal Division
Department of Insurance
1901 Harrison Street, 3rd Floor Mailroom
Oakland, CA 94612
...............................................................................
SECTION 1
-- PROPOSED NAME(S)
Requested
							 Name:
___________________________
1st Alternative Name
							 :
___________________________
2nd Alternative
							 Name:
___________________________
...............................................................................
SECTION 2
-- BACKGROUND
				  INFORMATION
Contact
							 Person:
Name
___________________________
Title
___________________________
Address
___________________________
email
___________________________
direct
							 phone
___________________________
fax
___________________________
Applicant Name and Address:
_______________________________________________________
_______________________________________________________
_______________________________________________________
_______________________________________________________
_______________________________________________________
Applicant's State of Domicile:
_______________________________________________________
Applicant's Federal Employer Identification
							 Number:
_______________________________________________________
Applicant's NAIC Number:
_______________________________________________________
Applicant's NAIC Group Name and NAIC Group Number (if
							 applicable):
_______________________________________________________
If Applicant is not an
_______________________________________________________
Affiliate (
see
, §
														2278.51(c)),
_______________________________________________________
name(s) of Applicant's
_______________________________________________________
owners or proposed owners:
_______________________________________________________
(attach separate page if
								needed)
Organizational Chart: Attach
							 organizational chart that identifies all Affiliates (
see
,
							 §
														2278.51(c)),
							 including parent companies and subsidiaries. If Applicant has not yet been
							 formed, the organizational chart must specify the proposed position of
							 Applicant on the organizational chart upon completion of Applicant's
							 formation
Classes of Insurance (per
_______________________________________________________
Insurance Code) transacted or
to be transacted in California:
_______________________________________________________
_______________________________________________________
_______________________________________________________
_______________________________________________________
Specialty lines (per Insurance
_______________________________________________________
Code) transacted or to be
transacted in California
_______________________________________________________
_______________________________________________________
_______________________________________________________
_______________________________________________________
_______________________________________________________
_______________________________________________________
_______________________________________________________
..........................
SECTION 3
-- APPLICANT SEEKING A NAME
				  CHANGE
If the Applicant is seeking approval of a proposed name
					 change, state the reason for the proposed name change.
..........................
SECTION 4
-- APPLICANT -- UNDERWRITTEN
				  TITLE COMPANY
If Applicant is, or will be, an underwritten title company,
					 state the following:
(A) all counties
				  in which business is, or will be, transacted:
(B) all title insurers that will underwrite
				  the policies offered by Applicant.
..........................