Form FIS0363 "Purchasing Group Change in Registration" - Michigan

What Is Form FIS0363?

This is a legal form that was released by the Michigan Department of Insurance and Financial Services - a government authority operating within Michigan. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on May 1, 2015;
  • The latest edition provided by the Michigan Department of Insurance and Financial Services;
  • 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 FIS0363 by clicking the link below or browse more documents and templates provided by the Michigan Department of Insurance and Financial Services.

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Download Form FIS0363 "Purchasing Group Change in Registration" - Michigan

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Validation Code 96-14-01
FIS 0363 (5/15) Department of Insurance and Financial Services Page 1 of 1
Purchasing Group Change in Registration
Any change in FEIN requires submission of
new FIS 0359 Purchasing Group Application.
Due within 10 days of effective date of change.
Name of Purchasing Group (if name is changing, enter previous name here and new name in first box below.)
Tax ID number (FEIN)
Check the box / boxes to indicate which registration
Effective date
New Information
information has changed:
of change
Purchasing Group name
Telephone Number
Principal Address
Mailing Address
Delete past Insurer
Add new Insurer and submit $25 fee per Insurer;
Include name & System ID number of Producer
placing business with the new Insurer
Delete Producer, Business Entity Producer, or
Risk Retention Group
Change Producer, Business Entity Producer, or
Risk Retention Group
Add state
Delete state
Change Officer or Director of the Purchasing
Group
Change Contact Person of Purchasing Group
(include email address for new contact person)
Other changes (describe)
Officer Certification: I certify that the information in this report, and any attachments included with it, is complete and correct.
Signature of Officer of the Purchasing Group
Date signed
Officer Name and Title (please type or print)
Name and telephone number of person to contact regarding this report
To add a new Insurer, submit completed & signed form with $25 fee per Insurer to:
To report all other changes, submit completed & signed form to:
Department of Insurance and Financial Services
Department of Insurance and Financial Services
PO Box 30165
PO Box 30220
Lansing, MI 48909-7665
Lansing, MI 48909-7720
Authority: PA 214 of 1989 requires submission of this form within 10 days of the effective date of any Purchasing Group registration information changes.
Failure to file properly may result in a compliance action against the Purchasing Group.
Validation Code 96-14-01
FIS 0363 (5/15) Department of Insurance and Financial Services Page 1 of 1
Purchasing Group Change in Registration
Any change in FEIN requires submission of
new FIS 0359 Purchasing Group Application.
Due within 10 days of effective date of change.
Name of Purchasing Group (if name is changing, enter previous name here and new name in first box below.)
Tax ID number (FEIN)
Check the box / boxes to indicate which registration
Effective date
New Information
information has changed:
of change
Purchasing Group name
Telephone Number
Principal Address
Mailing Address
Delete past Insurer
Add new Insurer and submit $25 fee per Insurer;
Include name & System ID number of Producer
placing business with the new Insurer
Delete Producer, Business Entity Producer, or
Risk Retention Group
Change Producer, Business Entity Producer, or
Risk Retention Group
Add state
Delete state
Change Officer or Director of the Purchasing
Group
Change Contact Person of Purchasing Group
(include email address for new contact person)
Other changes (describe)
Officer Certification: I certify that the information in this report, and any attachments included with it, is complete and correct.
Signature of Officer of the Purchasing Group
Date signed
Officer Name and Title (please type or print)
Name and telephone number of person to contact regarding this report
To add a new Insurer, submit completed & signed form with $25 fee per Insurer to:
To report all other changes, submit completed & signed form to:
Department of Insurance and Financial Services
Department of Insurance and Financial Services
PO Box 30165
PO Box 30220
Lansing, MI 48909-7665
Lansing, MI 48909-7720
Authority: PA 214 of 1989 requires submission of this form within 10 days of the effective date of any Purchasing Group registration information changes.
Failure to file properly may result in a compliance action against the Purchasing Group.