The application must be completed in its entirety. All questions must be answered and required items submitted. If an answer is "no", "none", or "not applicable", so state. No application will be considered completed until all requested information is received.
What To Use
The application must be either typed or written in ink.
If extra space is required to respond to any of the items in the notification, additional pages should be attached indicating the specific items for which the additional information is being provided.
The payment of the application fee required pursuant to N.C.G.S. § 58-89A-65(a) must be mailed at the time the notification is submitted.
The completed notification should be submitted to: Christine.Williams@ncdoi.gov.
Please contact the Financial Analysis and Receivership Division of the North Carolina Department of Insurance, Special Entities Section via email to Christine.Williams@ncdoi.gov or via phone to 919-807-6612 if you have any questions.