If any of the conditions below are true, please check the appropriate box. This form may be submitted in lieu of the requested information in the Commissioner's Order Number 03-0128.
Company NAIC No.:
Group NAIC No.:
__The above company has filed a withdrawal plan with the Texas Department of Insurance in accordance with Texas Insurance Code Article 21.49-2C, on the following date: __________
__The above company is no longer writing any new business for residential property and is non-renewing their residential property business when it comes up for renewal. In addition, if the company is transferring the business to an affiliate as described by Texas Insurance Code Article 21.49-1 § 2(a), name affiliate: ___________________________________________
__The above company does not write any residential property insurance as defined by Sec. 2
(2) of Texas Insurance Code Article 5.141. That is, insurance against loss to residential real property at a fixed location or tangible personal property provided in a homeowners policy, which includes a tenant policy, a condominium owners policy, or a residential fire and allied lines policy.
Signature of Company Officer/Designee Date
Printed Name of Company Officer/Designee Phone Number
Title of Company Officer/Designee Fax Number