Form D-174 "Securities Transaction Request Form for Outside Depositors" - California

What Is Form D-174?

This is a legal form that was released by the California Department of Insurance - a government authority operating within California. Check the official instructions before completing and submitting the form.

Form Details:

  • Released on September 1, 2015;
  • The latest edition provided by the California Department of Insurance;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form D-174 by clicking the link below or browse more documents and templates provided by the California Department of Insurance.

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Download Form D-174 "Securities Transaction Request Form for Outside Depositors" - California

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SECURITIES TRANSACTION REQUEST
Form D-174 (Revised 9/2015)
Outside Depositors Only
State of California
For Depository Use Only
Department of Insurance
Date of Deposit:
Request Number
300 Capitol Mall, Suite 14000
Sacramento, CA 95814
Date of Withdrawal:
0
Assigned by Dept. of Ins.
Substitution/
$ 0.00
$ 0.00
Check One:
Total Deposit Value of:
Deposit:
Withdrawal:
Initial Deposit
Additional Deposit
Withdrawal
Exchange
COMPANY INFORMATION
If New Company, check here
BANK INFORMATION
Company Name:
Bank Name:
Mailing Address:
Mailing Address:
Contact Name:
Contact Name:
E-mail Address:
E-mail Address:
Telephone & Fax #:
Telephone & Fax #:
Tax I.D. #:
NAIC/CDI #:
SECURITIES TO BE DEPOSITED
Description of Securities
Cusip / Serial / Certificate
Deposit Value
Market Value
Rating
Issue Date
(Include Source)
If depositing stock, identify whether common or preferred.
Number
Rate
Maturity Date
Par/Face Value
As of:
(Lower of Par or Market)
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
DEPOSIT GRAND TOTALS
$ 0.00
$ 0.00
$ 0.00
LIST SECURITIES TO BE WITHDRAWN ON REVERSE
SECURITIES TRANSACTION REQUEST
Form D-174 (Revised 9/2015)
Outside Depositors Only
State of California
For Depository Use Only
Department of Insurance
Date of Deposit:
Request Number
300 Capitol Mall, Suite 14000
Sacramento, CA 95814
Date of Withdrawal:
0
Assigned by Dept. of Ins.
Substitution/
$ 0.00
$ 0.00
Check One:
Total Deposit Value of:
Deposit:
Withdrawal:
Initial Deposit
Additional Deposit
Withdrawal
Exchange
COMPANY INFORMATION
If New Company, check here
BANK INFORMATION
Company Name:
Bank Name:
Mailing Address:
Mailing Address:
Contact Name:
Contact Name:
E-mail Address:
E-mail Address:
Telephone & Fax #:
Telephone & Fax #:
Tax I.D. #:
NAIC/CDI #:
SECURITIES TO BE DEPOSITED
Description of Securities
Cusip / Serial / Certificate
Deposit Value
Market Value
Rating
Issue Date
(Include Source)
If depositing stock, identify whether common or preferred.
Number
Rate
Maturity Date
Par/Face Value
As of:
(Lower of Par or Market)
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
DEPOSIT GRAND TOTALS
$ 0.00
$ 0.00
$ 0.00
LIST SECURITIES TO BE WITHDRAWN ON REVERSE
Form D-174 (Revised 2/2004)
Request Number
Company Name:
Assigned by Dept. of Ins.
SECURITIES TO BE WITHDRAWN
Cusip / Serial / Certificate
Market Value
Withdrawal Value
Description of Securities
Number
Rate
Maturity Dates
Par/Face Value
As of:
(Lower of Par or Market)
If withdrawing stock, identify whether common or preferred.
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
WITHDRAWAL GRAND TOTALS
$ 0.00
$ 0.00
$ 0.00
If additional space is needed, use plain paper following columnar format above and have signers initial and date each page.
AUTHORIZATION
COMPANY
FINANCIAL INSTITUTION
MUST BE COMPLETED BY AUTHORIZED COMPANY OFFICER
The insurer certifies that the substituted/additional deposit/withdrawal without replacement is in compliance with
We (depository) certify that this accounting is true and correct according to
Sections 11691 and 11691(c) of the California Insurance Code and Article 9.5, Subchapter 3, Chapter 5, Title 10 of
our best information and belief.
the California Administrative Code.
Depository
Seal
Signature of Company Officer
Print Name and Title
Date
Authorized Signature
Date
Signature of Company Officer
Print Name and Title
Date
Authorized Signature
Date
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