Get California Annual Re-registration Statement

The California Annual Re-Registration Statement is an important document that ensures your Risk Purchasing Group remains compliant with state regulations. This guide provides clear steps on how to efficiently fill out this form online, catering to users with varying levels of experience.

Follow the steps to complete the form effectively.

1. Press the ‘Get Form’ button to access the California Annual Re-Registration Statement and open it in the online editor.
2. Begin by entering the exact name of the Risk Purchasing Group in the first field, including any doing business as (DBA) names, if applicable.
3. In the next section, provide the state where the Risk Purchasing Group is domiciled, followed by the complete physical street address.
4. Next, fill in the mailing address, telephone number, facsimile number, and contact name, including their email address.
5. Provide the Federal Employer Identification Number (FEIN) for your Risk Purchasing Group in the following field.
6. If the administrative office of the Risk Purchasing Group is different from the previous responses, fill in the relevant details including company name, addresses, telephone number, facsimile number, and email contact.
7. Describe the classifications or sub-classifications of liability insurance the Risk Purchasing Group purchases, along with a brief overview of the members’ common business or activities.
8. List the insurance companies that the Risk Purchasing Group obtains liability insurance from, including the full name of the company, NAIC number, state of domicile, and the approximate number of California policyholders.
9. Provide the contact information for the knowledgeable person regarding the insurance program, including their name, address, telephone number, and email address.
10. Fill in the contact details for the individual who manages or administers the insurance program.
11. List the licensed insurance agents or brokers associated with the Risk Purchasing Group, providing their names, addresses, telephone numbers, and California license numbers.
12. Answer the questions regarding any legal or regulatory issues related to any officer or person on behalf of the Risk Purchasing Group, and attach a supplementary statement if necessary.
13. Submit the $200.00 annual registration renewal fee payable to the Insurance Commissioner of the California Department of Insurance.
14. Ensure to include notification of any changes reported in this form to the Insurance Commissioner within 30 days.
15. State the number of California policyholders for the specified years.
16. Finally, complete the signature section to affirm the accuracy of the information provided and include the date.
17. Once all sections are completed, save your changes, and then you can download, print, or share the filled form as needed.

Complete your California Annual Re-Registration Statement online today!