Fillable MA Secretary of the Commonwealth: Cert Of Change Of Principal Office Form

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MA Secretary of the Commonwealth: Cert Of Change Of Principal Office Form

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The Commonwealth of Massachusetts
William Francis Galvin
Secretary of the Commonwealth
One Ashburton Place, Boston, Massachusetts 02108-1512
Certificate of Change of Principal Office
(Insurers must file this form with the Secretary of the Commonwealth pursuant to
Massachusetts Insurance Laws - General Laws, Chapter 175, Section 34)
Massachusetts General Laws, Chapter 175, Section 34
I, of
Name of Clerk
Name of Insurance Co
m
pany
having its principal office at
Address of Insurance Co
m
pany
do hereby certify that pursuant to the Massachusetts General Laws, Chapter 175, Section 34, the directors
of said corporation have changed the principal office of the corporation to
Current
A
dd
re
ss of Insurance Co
m
pany
Subscribed this Under Penalties of Perjury.
Date Signed
Signature _
Signature of Clerk/Secretary/Assistant Secretary
I certify that it appears upon examination of this certificate, that Section 34 of Chapter 175 of the
Massachusetts General Laws has been complied with, and I approve said certificate on
.
Date Signed
Gary D. Anderson
Commissioner of Insurance
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signature
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dd mmm yyyy
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MA Secretary of the Commonwealth: Cert Of Change Of Principal Office Form

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Completed 17 May 2020

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