Fillable STANDARD CERTIFICATE REQUEST FORM (Department of Technology and Information)

Fill Online, Printable, Fillable, Blank STANDARD CERTIFICATE REQUEST FORM (Department of Technology and Information) Form

Use Fill to complete blank online DEPARTMENT OF TECHNOLOGY AND INFORMATION (DE) pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

STANDARD CERTIFICATE REQUEST FORM (Department of Technology and Information)

On average this form takes 11 minutes to complete

The STANDARD CERTIFICATE REQUEST FORM (Department of Technology and Information) form is 3 pages long and contains:

  • 0 signatures
  • 18 check-boxes
  • 35 other fields

Country of origin: US
File type: PDF

U.S.A. forms for Department of Technology and Information

BROWSE DEPARTMENT OF TECHNOLOGY AND INFORMATION (DE) FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
Insurance
Commissioner
Delaware
Department of Insurance
STANDARD CERTIFICATE REQUEST FORM
Mail payment and completed Certificate Request to:
Delaware Department of Insurance
Attn: BERG Certificates
1351 West North Street, Suite 101
Dover, DE 19904
Checks must be made payable to Delaware Department of Insurance
See page 3 for Fee Schedule. Pursuant to 18 Del. C. § 701 Fee Schedule – all fees shall be
collected in advance.
Please complete all necessary fields prior to submission. Incomplete forms will delay processing.
Contact berg@delaware.gov with questions
Date of Request:
Company Name:
NAIC # or FEIN #
Contact Person
Name
Contact Phone:
Contact Email:
Ship to address:
Select Shipping Method:
☐
United States Postal Service (USPS) Standard
☐ FedEx
FedEx Account # ___________________
First Overnight
☐
Priority
☐
2Day
☐
☐ UPS
UPS Account
# _____________________
Next Day Early
☐
Saver
☐
2Day
☐
2
1351 West North Street, Suite 101, Dover, DE 19904-2465 • www.delawareinsurance.gov
(302) 674-7300 Dover • (302) 739-5280 fax • (302) 577-5280 Wilmington
CERTIFICATE INFORMATION: Please list the # of requested certificates next to the
corresponding certificate type.
Note: Please use “*OTHER” section to indicate special requests or End of Year Effective
Dates
#
CERTIFICATE TYPE
CERTIFICATE TYPE
Cert. of Deposit
Cert. of Capital and Surplus
Cert. of Authorization
Cert. of Compliance, Capital & Surplus
Cert. of Compliance, Assets &
Liabilities
Cert. of Market Conduct
Cert. of Compliance/Good Standing
(same as COC)
Report of Exam (ROE)- click link for
free copy
UCAA Form 6 - Certificate of
Compliance
UCAA Form 7 - Certificate of Deposit
Certificate for use in other country: (Extra $10 for Notary)
☐ Brazil ☐ Honduras ☐ Venezuela
☐ China ☐ Mexico ☐ Vietnam
☐ Ecuador ☐ Panama
☐
Other – please specify:
CERTIFIED (Requests)
Certified – Annual Statement (must
provide hard Copy to Department)
Certified - License
Certified – Articles of Incorporation
(AOI)
Certified – Order (Include Order Type
under “Other”)
Certified – Bylaws
Certified – Quarterly Statement
Certified - Certificate of Authority
Certified Report of Exam – available for
free (click link)
3
1351 West North Street, Suite 101, Dover, DE 19904-2465 • www.delawareinsurance.gov
(302) 674-7300 Dover • (302) 739-5280 fax • (302) 577-5280 Wilmington
*OTHER:
FEES:
Pursuant to 18 Del. C. § 701 Fee Schedule – all fees shall be collected in advance:
• § 701(14) Certificates - $10 (unless notary or copies included)
• § 701(18) Copies of documents on file in the Department, ($.50 per page) minimum $5
• § 701(19) Certifying and affixing official seals - $10
• § 701(20) Certified copy of insurer certificate of authority or of any license issued under
this title - $10
Note: Risk Purchasing Groups do not use this form. Contact DOI_Tax@delaware.gov for
more information pertaining to Risk Purchasing Groups.
DEPARTMENT OF INSURANCE USE ONLY:
Date Request Received: _____________________
Date Request Processed: _____________________
Request Processed by: _______________________
Check #: ___________________________________
Check Amount: ______________________________
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

STANDARD CERTIFICATE REQUEST FORM (Department of Technology and Information)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 13 August 2020

Message

View Audit Log
Print With Audit Log
Duplicate Document