Instructions:
Answer each question on this application. If a question is not applicable, respond by indicating “not applicable.” Do not leave a question blank. Incomplete applications will be returned. Effective March 16, 2020 and until further notice, applications should be submitted electronically and hard-copy applications are not required. The electronic application should be signed and should include a detailed table of contents and should be in a single PDF document with bookmarks. Also, submit the proforma financial template in the excel format. The application and proformas should be e-mailed to hawi.chibessa1@dc.gov with a copy to sean.odonnell@dc.gov.
The application shall be accompanied by a $500 non-refundable application review fee and a $300 certificate of authority fee. If the application is denied, the certificate of authority fee will be returned. If paying by check, a copy of the check should be included in the PDF application and the check should be submitted to the:
DC Treasurer Insurance Bureau
PO Box 712180
Philadelphia, PA 19171-2180
Payment can also be accepted via ACH or wire transfer. Please contact Hawi Chibessa at hawi.chibessa1@dc.gov for ACH and wire instructions.
