09-2019 North Carolina Department of Insurance Authorized-2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering the Year and NAIC Code in the designated fields at the top of the form.
3. Fill in your Company Name, followed by the President or USA Manager’s Name. Ensure accuracy for proper identification.
4. Provide your FEIN/Alien Number, State/Country of Domicile, and NAIC Group Number to complete this section.
5. In the NAIC Group Name field, enter the appropriate name associated with your group.
6. Complete your Company Mailing Address, including City, State, and Zip Code for correspondence purposes.
7. Enter the Contact Person’s Name and their Phone Number to ensure direct communication.
8. Finally, provide the Contact’s Mailing Address and E-Mail Address for any follow-up inquiries.

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