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CA Department of Insurance

Certificate of Authority Application Forms

The California Department of Insurance's (CDI) Certificate of Authority Application forms are now available in Adobe's Portable Document Format (PDF). The Word documents may be downloaded to your computer. To view and complete these pdf forms on your browser, you must have Adobe Acrobat Reader on your computer. A free copy of the Adobe Acrobat Reader can be downloaded from our Free Document Readers web page.

Additional forms may need to be added or revised periodically, so keep checking back. Please submit the completed forms to:

California Department of Insurance
Corporate Affairs Bureau
45 Fremont Street, 24th Floor
San Francisco, CA 94105

If you have any questions about our admission process, please contact the CDI's Corporate Affairs Bureau by mailing your questions to the Bureau's address noted above, or by calling (415) 538-4035. We recommend you contact the CDI with any questions prior to submitting your application.

Certificate of Authority Application Forms
Application Checklist 

Form#01 - Admission to California 

Form#03 - Plan of Operation Vertification Form 

Smpl-#03 - Sample Plan of Operation

Form#07 - Individual Affidavit 

Form LIC 051-CIU Fingerprint Live Scan Service Request (Applicant) 

Form#08 - Organizational Affidavit 

Form#10 - Delegation of Insurer Functions Checklist 

Smpl-#10 - Sample Intercompany Service Agreement 

Smpl-#11 - Sample Custody Agreement 

Form#12 - Questionnaire

Form#16 - Appointment of Agent for Service of Process

Form#17 - Special Power of Attorney to Appoint and Certify Agents

Form#20 - Authorization for Disclosure of Financial Records

Form#26 - Certificate of Organization, Capital and Assets

Form#33a -  P&C Reinsurance Checklist

Form #33a2 - Reinsurance Arrangements

Form#33b -  Life Reinsurance Checklist

Form#35 - Subscription Agreement - California Life & Health Insurance Guarantee Association

Form#36 - Subscription Agreement - California Insurance Guarantee Association

Form#37 - Subscription Agreement - California Automobil Assigned Risk Plan

Form#42a - Application Pending Notice

Form#42b - Rate Filing - General

Rate Filing Application

Form#43a - Application Pending Notice

Form#43b - Rate Filing - Workers' Compensation

Form WCD-001 Letter of Credit for Workers' Compensation Deposit

Form WCD-002 Workers' Compensation Deposit Trust and Security Agreement

Form AR-1 - Certificate of Assuming Insurer

*Forms 18(a), (b) and (c) are no longer in use

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