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Registered Agent Information Form

District of Columbia
Department of Insurance, Securities and Banking
Registered Agent Information Form

 

Please complete one form for each carrier licensed in DC.  Do not enter PO Boxes as the registered agents’ address.  Registered agents must be in the District of Columbia or within 10 miles of the District.  Please enter your NAIC Code and Company name.  Only complete the contact information if you select “e” under Registered Agent.

Contact Information
Only complete if you selected "e" above.
Street Address
Floor - Suite - Room, if applicable
To the attention of, if applicable
Individual Completing This Form
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