Corporations Code §§ 2105, 2106, 2106.5, Revenue and Taxation Code § 23153 2014 California Secretary of State
S&DC-INS (REV 04/2014)
Statement and Designation by
Foreign Insurer Corporation
To qualify an insurer corporation from another state or country to transact
intrastate business in California, fill out this form, and submit for filing
along with:
– A $100 filing fee,
A certificate of good standing, issued within the last six (6) months by
the agency where the corporation was formed, and
A certificate by the California Insurance Commissioner approving the
corporate name. For more information, go to
– A separate, non-refundable $15 service fee also must be included, if
you drop off the completed form.
Important! Corporations in California may have to pay a minimum $800
yearly tax to the California Franchise Tax Board. For more information,
go to
This Space For Office Use Only
For questions about this form, go to
Corporate Name (List the exact name of the corporation, as shown in the certificate of good standing. If the name of the corporation is
not available for use in the State of California, the corporation must qualify under an assumed name. E.g., "[list the exact name] which will
do business in California as [list the proposed assumed name]." For general corporate name requirements and restrictions in California, go
to )
Corporate History
State or foreign country where this corporation was formed: _________________________________________________________________________
Service of Process (List a California resident or a California registered corporate agent that agrees to be your agent to accept service
of process in case your corporation is sued. You may list any adult who lives in California. You may not list your own corporation as the
agent. Do not list an address if the agent is a California registered corporate agent as the address for service of process is already on file.)
a. _______________________________________________________________________________________________________________________________________________
Agent's Name
b. _______________________________________________________________________________________________________________________________________________
Agent's Street Address (if agent is not a corporation) - Do not list a P.O. Box City (no abbreviations) State Zip
The corporation named in Item 1 above irrevocably consents to service of process directed to it upon the agent
designated above, and to service of process on the California Secretary of State if that agent or that agent's successor
is no longer authorized to act or cannot be found at the address given.
Corporate Addresses
a. _______________________________________________________________________________________________________________________________________________
Street Address of Principal Executive Office - Do not list a P.O. Box City (no abbreviations) State Zip
b. _______________________________________________________________________________________________________________________________________________
Street Address of Principal Office in California, if any - Do not list a P.O. Box City (no abbreviations) State Zip
c. _______________________________________________________________________________________________________________________________________________
Mailing Address of Principal Executive Office, if different from 4a or 4b City (no abbreviations) State Zip
Insurer Statement
This corporation will be subject to the California Insurance Code as an insurer.
Read and sign below: This form must be signed by an officer of the foreign corporation.
___________________________________________________________ ________________________________________________ ___________________________________
Sign here Print your name here Your officer title
Make check/money order payable to: Secretary of State
Upon filing, we will return one (1) uncertified copy of your filed
document for free, and will certify the copy upon request and
payment of a $5 certification fee.
By Mail
Secretary of State
Business Entities, P.O. Box 944260
Sacramento, CA 94244-2600
Secretary of State
1500 11th Street, 3rd Floor
Sacramento, CA 95814
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Secretary of State
Business Programs Division
Business Entities, P.O. Box 944260, Sacramento, CA 94244-2600
Mail Submission Cover Sheet
Submit this document with your filing. This information will be used to resolve questions with the filings
attached. This form will be treated as correspondence and will not be made part of the filed document.
Make all checks payable to the Secretary of State.
Do not include a $15 counter fee when submitting documents by mail.
Standard processing time for submissions to this office is approximately 5 business days from receipt. All
submissions are reviewed in the date order of receipt. For updated processing time information, visit
Optional Copies and Certificates:
A customer who submits documents with a filing fee of $25.00 or more will receive one (1) uncertified copy of the
documents for free and, at the time of filing, the free copy may be certified for a $5.00 certification fee.
Customers requesting additional copies must include a $1.00 for the first page and $.50 for each additional page.
Each certified copy requires an additional $5.00 certification fee.
At the time of filing, a Certificate of Status/Good Standing may be requested with a payment of a $5 fee.
Contact Person to resolve questions with this filing:
(Please type or print legibly)
First Name: __________________________________________________ Last Name: _______________________________________________
Phone: ______________________________________________________
Entity Information: (Please type or print legibly)
Name: __________________________________________________________________________________________________________________
Entity Number (if applicable): _____________________________________
Comments: _____________________________________________________________________________________________________________
Return Address: For written communication from the Secretary of State related to this document, or if
purchasing a copy of the filed document enter the name of a person or company and the mailing address.
Secretary of State Use Only
Doc Submission Cover - Corp (Est. 06/2016)
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