How to Fill Out NAIC Form C (w/Examples) + FAQs

NAIC Form C is the Summary of Changes to Registration Statement that an insurer in a holding company group files with its state insurance commissioner each year, alongside its annual Form B registration statement, to flag every change since the prior year’s filing. It is a short cover document, but a wrong or missing entry on it can trigger regulator follow-up, delay your group’s registration review, and raise questions about whether your insurer is hiding a material change.

Every insurer that must register under its state’s Insurance Holding Company System Regulatory Act must file Form C together with Form B, and most states set the annual deadline at on or before June 1. Across the roughly 50 states and territories that have adopted the NAIC model regulation, thousands of insurers file a Form C each year, and the single most common error is the one that looks harmless: writing “No changes” when a reportable change actually happened.

This guide walks you through the form line by line, shows you three full filled-out examples, and answers the questions filers ask most.

• 📄 What Form C is, who must file it, and how it pairs with Form B
• 🗂️ Every document and data point to gather before you open the form
• ✍️ A line-by-line walkthrough of each box, with sample entries you can copy
• 🧮 Three real-world scenarios filled out from top to bottom
• ⚠️ The mistakes that get filings flagged and how to dodge every one

What the Form Is and Who Must File It

Form C is the Summary of Changes to Registration Statement under Section 15 of the Insurance Holding Company System Model Regulation. Its job is narrow but important. It does not repeat all the data in your Form B. Instead, it gives the commissioner a quick map of what changed since last year, with specific references to the Item numbers in your annual Form B registration statement.

The form exists because regulators review hundreds of holding company filings each spring and cannot reread every full Form B side by side with last year’s version. Form C points them straight to the changes. The JD Supra summary of the Model Laws describes it plainly: the Form C Statement, filed with the current annual Form B, provides a summary of the changes from the prior year’s Form B.

Who must file it is simple to state and easy to get wrong. Under Section 15 of the model regulation, any insurer that is required to file an annual Form B registration statement is also required to furnish Form C. That means a domestic insurer inside a holding company system files both, every year, even in a quiet year with no changes. A foreign insurer that registers through its state of domicile usually does not file a separate Form C in every state where it does business, but it must confirm its home-state filing.

The agency that receives the form is your insurer’s domiciliary state department of insurance, not the NAIC itself. The NAIC writes the model; the states adopt and enforce it. The statute that requires it is your state’s enactment of Section 4 of the Act, and the penalty for skipping it ranges from fines to administrative action against your certificate of authority, depending on the state.

A quick note on naming. Some states title the form “Summary of Registration Statement” and others use “Summary of Changes to Registration Statement,” but it is the same Form C. The current NAIC model carries a 2021 revision date on the regulation, while the form text itself traces to the January 2011 reporting forms; always check that your state’s posted version matches your filing year.

Before You Start: Documents and Information You Need

Form C cannot be completed in a vacuum. It is built entirely on top of your current and prior Form B filings, so gather those first. Pulling everything before you open the form prevents the back-and-forth that delays a filing.

Here is the pre-filing checklist. Each item matters, and missing one creates a real problem.

• Your insurer’s current-year Form B registration statement, because Form C summarizes changes against it and references its Item numbers; without it, you cannot cite items correctly.
• Last year’s filed Form B, because Form C is a year-over-year comparison, and you cannot describe a change without the prior baseline.
• The complete organizational chart for the holding company system, since ownership and affiliate changes (Item 2 of Form B) are the most common reportable changes.
• A current list of directors and executive officers of the ultimate controlling person, because Item 4 changes are reportable when someone first becomes, or stops being, a director or officer of the UCP.
• Records of every affiliate transaction since the last filing, because effectuated or changed transactions must be described, including the flow of funds between affiliates.
• The dollar amounts and effective dates of each change, because the commissioner requires the date and dollar amount of each change to evaluate it.
• Any amendments filed during the intervening year, because Form C must reference them so the regulator can trace the paper trail.
• The full legal name and NAIC company code of each insurer covered, because the cover page must list each insurer the registrant files on behalf of, and a wrong NAIC code misroutes the filing.
• The name, title, address, and phone number of your filing contact, because the department sends all correspondence to that person and a missing contact stalls communication.
• Authority to sign, such as an officer title or power of attorney, because the certification must be signed by an authorized officer or the filing is not valid.

If any item is missing, stop and find it. A Form C built on the wrong prior-year baseline or a stale org chart is worse than late, because it can be wrong in ways the regulator catches.

Where to Get the Form and How to Access It

You get Form C from your domiciliary state’s department of insurance, since each state hosts its own version of the NAIC model form. The form is short, usually one or two pages, and most departments post it as a fillable Word document or PDF. The official NAIC model regulation with reporting forms is the master source if you want to see the baseline language every state copies.

State examples make this concrete. The California Department of Insurance posts its Form C as a Word document, Pennsylvania posts its Form C as a PDF, and Utah posts its Form C under Rule R590-70. Use your own state’s version, because captions and signature blocks vary slightly.

A key point from Section 4 of the model regulation: the forms “are not intended to be blank forms which are to be filled in.” The filed statement must contain the numbers and captions of all items, but you prepare your answers as a typed document, not by scribbling in blanks. Most filers recreate the form’s headings in a Word file and type full answers beneath each one. Statements should be prepared electronically, be easily readable, be in English, and state monetary values in U.S. dollars.

Step-by-Step: How to Fill Out NAIC Form C Line by Line

Work through the form top to bottom. Below, each box and section gets its own walkthrough with a plain-English explanation, how to answer it, a sample entry, an edge case, a common mistake, and a misconception to drop.

1. State of Filing (“Filed with the Insurance Department of the State of ____”)

This line asks which state’s insurance department you are filing with. It sets the legal home of the filing.

To answer it, type the full name of your insurer’s domiciliary state on the blank line. Use the state where the insurer is organized, not where it writes the most business. Spell out the state name rather than abbreviating it.

For example, an insurer organized in California writes California on this line.

The common edge case is an insurer redomesticated during the year. If your insurer moved its domicile, use the current domiciliary state and note the redomestication as a change in the body of the form.

A frequent mistake is filing with the wrong state, such as the state of largest premium volume instead of domicile, which sends the form to a department that does not regulate your group’s registration. The consequence is a rejected or misrouted filing and a missed deadline.

The misconception to drop is that Form C goes to the NAIC. It does not; it goes to your state department, because the NAIC only publishes the model.

2. Name of Registrant (“By ____”)

This box asks for the insurer or holding company entity that is making the filing. The registrant is the entity legally responsible for the statement.

To answer, type the full legal name of the registrant exactly as it appears on its certificate of authority. Do not use a trade name, a “doing business as,” or an abbreviation.

For example, Golden State Mutual Insurance Company is entered as the registrant, not Golden State Mutual or GSM.

The edge case is consolidated filing. Under Section 17 of the model regulation, one authorized insurer may file on behalf of affiliated insurers, so the registrant may be the principal insurer in the group rather than each individual company.

The common mistake is naming the holding company parent as registrant when the regulation expects the registering insurer, which can confuse the regulator about who carries the duty. The consequence is a follow-up letter asking the group to clarify the filer.

The misconception to drop is that the registrant must be the ultimate controlling person. It is the registering insurer, which is usually a subsidiary insurer, not the top parent.

3. Insurers Covered (“On Behalf of Following Insurance Companies — Name / Address”)

This section asks you to list every insurance company that the filing covers. It defines the scope of the Form C.

To answer, type the full legal name and complete mailing address of each insurer covered by the filing, one per line. Many states also expect the NAIC company code and state of domicile beside each name, as shown on the Pennsylvania Form C.

For example, a group lists Golden State Mutual Insurance Company, 100 Market St., San Jose, CA, NAIC #12345, domicile CA.

The edge case is a large group with many insurers. List all of them; if space runs out, attach a continuation schedule and reference it on the form rather than leaving any insurer off.

The common mistake is omitting an affiliated insurer that should be covered, which leaves part of the group unregistered for the year. The consequence is that the missing insurer can be cited for failing to file.

The misconception to drop is that you only list insurers that had changes. You list every insurer covered by the registration, even those with no changes this year.

4. Date

This line asks for the date you are submitting the Form C. It anchors the filing to your annual cycle.

To answer, enter the filing date in your state’s expected format, typically the month, day, and year. Make sure it falls on or before your state’s deadline, commonly June 1.

For example, a filer submitting in spring writes May 28, 2026.

The edge case is an amended or change filing. Per Section 7 of the model regulation, a change filing carries the phrase “Change No. [number] to” at the top and shows the date of the change, not the original filing date.

The common mistake is dating the form after the statutory deadline, which makes the filing late on its face. The consequence is exposure to late-filing penalties even if the substance is correct.

The misconception to drop is that the date can match the prior year’s filing date out of habit. Each year’s Form C carries its own current date.

5. Contact for Notices (“Name, Title, Address and Telephone Number of Individual to Whom Notices and Correspondence Should Be Addressed”)

This box asks who at your company the department should contact about the filing. It is the regulator’s single point of contact.

To answer, type the full name, job title, mailing address, and phone number of the responsible person. Use someone who can actually answer questions about the filing, usually a compliance officer or financial reporting lead.

For example, Maria Lopez, Vice President of Compliance, 100 Market St., San Jose, CA 95113, (408) 555-0142.

The edge case is using a P.O. Box. A P.O. Box is acceptable for mail, but include a phone number and email so the department can reach the person quickly during review.

The common mistake is listing a generic department or a person who has left the company, which means regulator questions go unanswered. The consequence is delay and the appearance that the group is unresponsive.

The misconception to drop is that this must be an officer. The contact can be a knowledgeable staff member; the officer requirement applies to the signature and certification, not this contact line.

6. Description of Changes (the Body of Form C)

This is the heart of the form. It asks for a brief description of all items in the current Form B that represent changes from the prior year’s Form B.

To answer, walk through your current Form B item by item, and for each change write a short description that includes the date and dollar amount of the change, references the specific Form B Item number, and identifies any amendment filed during the year. Group the descriptions by Form B Item number so the regulator can follow along.

For example, Item 5 (Affiliate Transactions): On 09/15/2025, the insurer entered a $2,000,000 surplus note with parent Acme Holdings; see Amendment No. 1 to Form B filed 09/30/2025.

The edge case is a year with no changes at all. You do not leave this blank; you write an affirmative statement such as No changes from the prior year’s annual registration statement, because the regulation requires a statement to that effect when an answer is negative.

The common mistake is vague wording with no Item reference, dollar amount, or date, which fails the requirement that the description permit proper evaluation by the commissioner. The consequence is a request for more information that restarts the review clock.

The misconception to drop is that small changes can be skipped. Two narrow rules apply: under Item 2, report only voting-security changes that hit 10% or more, cause a loss or transfer of control, or involve a partnership interest; under Item 4, report only when someone first becomes a director or officer of the ultimate controlling person, leaves that role, or is named its president.

7. Statement on Effectuated and Changed Transactions

This part of the body asks what happened to transactions you disclosed in last year’s Form B. It tracks whether planned deals actually closed.

To answer, for each prior-year transaction that changed, describe the nature of the change; for each that was completed, furnish the mode of completion and any flow of funds between affiliates that resulted. Tie each entry to the original disclosure.

For example, The intercompany loan disclosed last year was effectuated on 01/10/2026 by wire transfer of $5,000,000 from the insurer to affiliate Acme Services LLC.

The edge case is a transaction that was disclosed but never happened. Say so directly, noting that the prior-year transaction was not consummated, so the regulator does not assume hidden movement of funds.

The common mistake is reporting that a deal “closed” without showing the flow of funds, which leaves the regulator unable to trace money between affiliates. The consequence is a detailed follow-up inquiry into intercompany cash movement.

The misconception to drop is that completed transactions need no mention because they are “done.” The regulation specifically requires reporting the completion and the resulting fund flow.

8. Anti-Avoidance Statement

This required statement asks you to confirm that recent transactions were not structured to dodge regulatory thresholds. It is a good-faith certification.

To answer, include the regulation’s required language: a statement that transactions entered into since the prior year’s filing are not part of a plan or series of like transactions whose purpose is to avoid statutory threshold amounts and the review that might otherwise occur. Copy the wording closely.

For example, The insurer states that transactions entered into since the prior filing are not part of a plan or series of like transactions intended to avoid statutory thresholds or review.

The edge case is a group with many small affiliate transactions. Even if each is below threshold, you still include this statement, because the rule targets splitting one big transaction into several small ones.

The common mistake is omitting this statement entirely, which leaves a required element off the form. The consequence is an incomplete filing that the department can reject.

The misconception to drop is that this statement is optional boilerplate. It is mandated by the model regulation’s Form C instructions.

9. Signature and Certification

The final block asks an authorized officer to sign and certify the filing under Section 4 of the Act. It makes the statement legally binding.

To answer, complete the signature block with the city and state of signing, the date, the name of the applicant, and the signature and title of the signing officer, with an attesting officer’s signature. Then complete the certification, where the officer swears the statement was duly executed, that the officer is authorized, and that the facts are true to the best of his or her knowledge, information, and belief.

For example, Signed at San Jose, California, this 28th day of May, 2026, by Maria Lopez, Vice President of Compliance, with the attesting secretary signing below.

The edge case is signing under a power of attorney. Section 4 allows it, but you must file a copy of the power of attorney with the statement.

The common mistake is filing an unsigned or unconformed copy, which the regulation does not accept, since at least one copy must be signed and unsigned copies must be conformed. The consequence is a rejected filing returned for proper signature.

The misconception to drop is that any employee can sign. The certification requires a person authorized to execute and file the instrument, normally an executive officer such as the CEO, CFO, treasurer, secretary, or controller.

Three Filled-Out Examples Using Real Scenarios

Below are three common filing patterns. Each follows one named filer through the key boxes of Form C.

Scenario A: A Quiet Year With No Changes (Maria Lopez)

Maria Lopez files for Golden State Mutual Insurance Company, a single California-domiciled insurer in a small holding company group that had no reportable changes this year.

Form Section	What Maria Enters
State of Filing	California
Name of Registrant	Golden State Mutual Insurance Company
Insurers Covered	Golden State Mutual Insurance Company, San Jose, CA, NAIC #12345
Date	May 28, 2026
Contact for Notices	Maria Lopez, VP Compliance, (408) 555-0142
Description of Changes	No changes from the prior year’s annual registration statement
Effectuated Transactions	Not applicable; no transactions were disclosed last year
Anti-Avoidance Statement	No transactions were entered to avoid statutory thresholds
Signature and Certification	Signed and certified at San Jose, CA, by Maria Lopez, VP Compliance

Scenario B: An Affiliate Transaction and a New Officer (Marcus Reed)

Marcus Reed files for Liberty Plains Insurance Company, a Texas-domiciled insurer that added a surplus note from its parent and named a new president of the ultimate controlling person.

Form Section	What Marcus Enters
State of Filing	Texas
Name of Registrant	Liberty Plains Insurance Company
Insurers Covered	Liberty Plains Insurance Company, Austin, TX, NAIC #67890
Date	May 30, 2026
Contact for Notices	Marcus Reed, Director of Regulatory Affairs, (512) 555-0199
Description of Changes	Item 5: 09/15/2025, $2,000,000 surplus note from parent Acme Holdings; Item 4: Jane Doe named President of UCP on 11/01/2025
Effectuated Transactions	Surplus note effectuated 09/15/2025; $2,000,000 wired from Acme Holdings to insurer
Anti-Avoidance Statement	The surplus note is not part of a plan to avoid statutory thresholds
Signature and Certification	Signed and certified at Austin, TX, by Marcus Reed under power of attorney on file

Scenario C: An Ownership Change Above 10% (Aisha Bello)

Aisha Bello files for Summit Health Insurance Company, a New York-domiciled insurer whose ultimate controlling person changed when a new investor crossed the 10% voting threshold.

Form Section	What Aisha Enters
State of Filing	New York
Name of Registrant	Summit Health Insurance Company
Insurers Covered	Summit Health Insurance Company, Albany, NY, NAIC #54321
Date	May 27, 2026
Contact for Notices	Aisha Bello, Chief Compliance Officer, (518) 555-0177
Description of Changes	Item 2: On 03/01/2026, Northstar Capital acquired 18% of voting securities, resulting in a transfer of control; see Form A approved 02/15/2026
Effectuated Transactions	Acquisition effectuated 03/01/2026; $40,000,000 paid by Northstar Capital to selling shareholders
Anti-Avoidance Statement	The acquisition is a single transaction, not structured to avoid thresholds
Signature and Certification	Signed and certified at Albany, NY, by Aisha Bello, Chief Compliance Officer

How to File the Completed Form

How you file depends on your state, since each department sets its own channel and copy requirements. Below are the main channels under the NAIC model and common state practice.

Mail or personal delivery is the traditional channel named in Section 4 of the model regulation. The regulation directs that the required number of complete copies, including exhibits, be filed with the commissioner by personal delivery or mail to the department’s address, with at least one copy signed and any unsigned copies conformed. North Dakota’s rule, for example, requires two complete copies sent to its Commissioner of Insurance with at least one signed, as shown in its holding company chapter. Keep your stamped or certified-mail receipt as proof of filing.

Electronic and portal filing is now standard in many states. The model regulation says statements should be prepared electronically, and many departments accept or require submission through a state filing portal or by secure email. California, for instance, posts its Form C and annual filing instructions on its insurer financial filing page; check your state’s instructions for the exact upload location. Save the portal confirmation or email receipt as your proof of filing.

There is generally no separate filing fee for Form C itself, because it accompanies the annual Form B registration. The processing time is not a fixed approval window like Form A’s 60-day clock; Form C is a registration filing the department reviews and keeps on file, and it may send follow-up questions if a change description is unclear. Whatever channel you use, file on or before your state’s deadline, which is on or before June 1 in most adoptions of the Act.

What Happens After You File

After you file, the department logs your Form C with your annual Form B and reviews the two together. The reviewer uses Form C as the index to find every change you flagged and confirm it matches the underlying Form B detail.

If a change description is vague, undated, or missing a dollar amount, expect a follow-up letter or email asking for clarification. Responding fast keeps your group’s registration current; a slow or incomplete response can stall the review and draw scrutiny. The acquisition and holding-company compliance overview notes that holding company obligations like Form B and its summary persist for the life of the ownership relationship, so this is an annual cycle, not a one-time event.

If you reported a material change, the department may open a deeper inquiry, request amendments, or coordinate with the lead state in a multi-state group. If everything checks out, no news is the good news: the filing is accepted, kept on file, and your insurer remains in good standing on its registration. Mark next year’s deadline now, because the cycle repeats every spring.

Mistakes to Avoid When Filling Out the Form

Form C is short, so each line carries weight. These are the errors that most often cause problems.

• Writing “No changes” when a reportable change occurred, which can look like concealment and undermine the certification’s truthfulness.
• Leaving the description blank in a no-change year, which violates the rule that a negative answer still needs an affirmative statement.
• Omitting the date or dollar amount of a change, which fails the requirement that descriptions permit proper evaluation by the commissioner.
• Failing to reference the specific Form B Item number, which forces the reviewer to guess and triggers a follow-up.
• Reporting a sub-10% voting change under Item 2, which clutters the filing with information the rule says to exclude.
• Missing an Item 4 officer change at the ultimate controlling person, which leaves a required leadership change unreported.
• Saying a transaction “closed” without showing the flow of funds, which leaves intercompany cash movement untraceable.
• Dropping the anti-avoidance statement, which removes a required element and can void the filing as incomplete.
• Filing an unsigned or unconformed copy, which the regulation does not accept and which the department returns.
• Letting a non-officer sign without authority, which fails the certification’s requirement of an authorized executor.
• Filing after the June 1 deadline, which exposes the insurer to late-filing penalties even when the content is right.
• Sending the form to the wrong state or to the NAIC instead of the domiciliary department, which misroutes the filing and can blow the deadline.

Do’s and Don’ts

Keep these in front of you while you work.

Do’s:

• Do start from your current and prior Form B, because Form C is a comparison and needs both baselines.
• Do reference each change by Form B Item number, because that is how the reviewer cross-checks your summary.
• Do include the date and dollar amount of every change, because the regulation requires enough detail to evaluate it.
• Do include the required anti-avoidance statement, because it is mandated, not optional.
• Do have an authorized officer sign and certify, because the filing is not valid without it.
• Do keep your proof of filing, because you may need to show the date you met the deadline.

Don’ts:

• Don’t report changes below the Item 2 and Item 4 thresholds, because the rule tells you to exclude them.
• Don’t leave any section blank, because a negative answer still requires an affirmative statement.
• Don’t paraphrase or skip the form’s captions, because the filed statement must contain the numbers and captions of all items.
• Don’t file with the NAIC, because the NAIC only publishes the model and your state department is the filer.
• Don’t reuse last year’s date, because each Form C carries its own current filing date.
• Don’t wait until June 1, because a last-minute glitch can push you past the deadline.

Pros and Cons of Filing on Your Own vs. With Help

Many insurers handle Form C in-house, while others use outside counsel or a compliance vendor, especially for complex groups.

Pros of filing on your own:

• Lower cost, because you avoid outside legal or consulting fees on a short, routine form.
• Faster turnaround, because your in-house team already knows the group’s structure and prior filings.
• Better institutional knowledge, because your staff sees the year’s changes firsthand.
• Direct control, because you manage the deadline and the contact relationship with the department.
• Easier year-over-year continuity, because the same team carries forward the prior baseline.

Cons of filing on your own:

• Risk of missing a reportable change, because in-house staff may not catch a subtle Item 2 or Item 4 trigger.
• Threshold confusion, because the 10% and officer-change rules are easy to misapply.
• State-by-state variation, because captions and copy requirements differ and an internal team may not track all of them.
• Certification exposure, because an authorized officer is swearing to accuracy under the Act.
• Limited backup, because a thin compliance team can fall behind during a busy filing season.

FAQs

Is Form C filed every year even when nothing changed?

Yes. Any insurer required to file Form B must also file Form C each year, and in a no-change year you state that there are no changes rather than skipping the filing.

Is Form C filed with the NAIC?

No. It is filed with your insurer’s domiciliary state department of insurance; the NAIC only publishes the model regulation that states adopt.

Is there a filing fee for Form C?

No. Form C generally carries no separate fee because it accompanies the annual Form B registration statement, though states may charge for the overall registration.

Do I list every insurer in the group or only ones with changes?

No. You list every insurer covered by the registration in the “On Behalf of Following Insurance Companies” section, not only those that had changes this year.

Do I report a 5% increase in an affiliate’s voting securities in the Item 2 box?

No. Item 2 changes are reported only when they reach 10% or more, cause a loss or transfer of control, or involve acquisition or loss of a partnership interest.

Do I report a new vice president of the ultimate controlling person under Item 4?

No. Item 4 changes are reported only when someone first becomes a director or executive officer of the UCP, leaves that role, or is named president of the UCP.

Is the deadline the same in every state?

No. Most states set it on or before June 1 to match Form B, but you must confirm your own state’s date because adoptions vary.

Can someone other than an officer sign the certification?

No. The certification must be signed by a person authorized to execute and file it, normally an executive officer, unless a power of attorney is filed.

Do I need to describe a transaction from last year that actually closed?

Yes. You must furnish the mode of completion and any flow of funds between affiliates for a prior-year transaction that was effectuated.

Is the anti-avoidance statement optional?

No. The model regulation requires a statement that transactions were not part of a plan to avoid statutory thresholds and review.

Can I file an unsigned electronic copy?

No. At least one copy must be signed in the prescribed manner, and any unsigned copies must be conformed to match the signed one.

Does a foreign insurer file a separate Form C in every state where it operates?

No. A foreign insurer generally satisfies the requirement through its state of domicile, though other states may ask for a copy of that home-state filing.

Should I write the name as it appears on the certificate of authority?

Yes. Use the registrant’s full legal name as licensed, because the department matches the filing to your certificate of authority records.