Form A-174 "Securities Transaction Request" - California

What Is Form A-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 A-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 A-174 "Securities Transaction Request" - California

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SECURITIES TRANSACTION REQUEST
Form A-174 (Revised 9/2015)
California Insurance Code Section
(Select link for A174 Instructions)
Request Number
Complete One Only
State of California
General Deposit (940/955) State
Department of Insurance
Workers Compensation (11691)
300 Capitol Mall, Suite 14000
Other (Specify)
Sacramento, CA 95814
Assigned by Dept. of Insurance
Substitution/
Check One Only:
Check One or Both (if applicable)
Initial Deposit
Additional Deposit
W ithdrawal
Book Entry
Physical Security
Exchange
COMPANY INFORMATION
BANK INFORMATION FOR INTEREST PAYMENT If change, check here
AGENT INFORMATION FOR SECURITIES DEPOSITS
If new company, check here
Company Name
Bank Name
Agent Name
Bank ABA # (9 digit)
Agent ABA # (9 digit)
Mailing Address
Bank Account #
DTC/Broker Code
FFC# (If applicable)
FED Broker Code
Contact Name
Mailing Address
Mailing Address
Telephone & Fax #
E-mail Address
Contact Name
Contact Name
Tax I.D. #
Telephone & Fax #
Telephone & Fax #
NAIC/CDI #
Email Address
Email Address
SECURITIES TO BE DEPOSITED
Description of Securities
Cusip / Serial / Certificate
Rate
Issue Date
Maturity Date
Par/Face Value
Deposit Value
Market Value
Rating
Number
(Lower of Par or Market)
If depositing stock, identify whether common or preferred.
As of:
(Include Source)
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
LIST SECURITIES TO BE WITHDRAWN ON REVERSE
DEPOSIT GRAND TOTALS
Submit One Original to: California Department of Insurance Securities Transaction Unit 300 Capitol Mall Suite 14000 Sacramento CA 95814
SECURITIES TRANSACTION REQUEST
Form A-174 (Revised 9/2015)
California Insurance Code Section
(Select link for A174 Instructions)
Request Number
Complete One Only
State of California
General Deposit (940/955) State
Department of Insurance
Workers Compensation (11691)
300 Capitol Mall, Suite 14000
Other (Specify)
Sacramento, CA 95814
Assigned by Dept. of Insurance
Substitution/
Check One Only:
Check One or Both (if applicable)
Initial Deposit
Additional Deposit
W ithdrawal
Book Entry
Physical Security
Exchange
COMPANY INFORMATION
BANK INFORMATION FOR INTEREST PAYMENT If change, check here
AGENT INFORMATION FOR SECURITIES DEPOSITS
If new company, check here
Company Name
Bank Name
Agent Name
Bank ABA # (9 digit)
Agent ABA # (9 digit)
Mailing Address
Bank Account #
DTC/Broker Code
FFC# (If applicable)
FED Broker Code
Contact Name
Mailing Address
Mailing Address
Telephone & Fax #
E-mail Address
Contact Name
Contact Name
Tax I.D. #
Telephone & Fax #
Telephone & Fax #
NAIC/CDI #
Email Address
Email Address
SECURITIES TO BE DEPOSITED
Description of Securities
Cusip / Serial / Certificate
Rate
Issue Date
Maturity Date
Par/Face Value
Deposit Value
Market Value
Rating
Number
(Lower of Par or Market)
If depositing stock, identify whether common or preferred.
As of:
(Include Source)
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
LIST SECURITIES TO BE WITHDRAWN ON REVERSE
DEPOSIT GRAND TOTALS
Submit One Original to: California Department of Insurance Securities Transaction Unit 300 Capitol Mall Suite 14000 Sacramento CA 95814
Request Number
Form A-174 (Revised 9/2015)
Company Name
Assigned by Dept. of Insurance
BANK INFORMATION FOR PRINCIPAL PAYMENT (CASH)
AGENT INFORMATION FOR SECURITY RELEASE
Bank Name
Agent Name
Bank ABA # (9 digit)
Agent ABA # (9 digit)
Bank Account #
Agent Account #
FFC # (if applicable)
FED Broker Code
FFC # (if applicable)
DTC Broker Code
Mailing Address
Mailing Address
Contact Name
Contact Name
Telephone & Fax #
Telephone & Fax #
Email Address
Email Address
SECURITIES TO BE WITHDRAWN
Description of Securities
Market Value
Deposit Value
Cusip / Serial / Certificate
If withdrawing stock, identify whether common or preferred.
Number
Rate
Maturity Date
Par/Face Value
As of:
(Lower of Par or Market)
1
2
3
4
5
6
7
8
9
10
WITHDRAWAL GRAND TOTALS
AUTHORIZATION
COMPANY
DEPARTMENT OF INSURANCE
MUST ALWAYS BE COMPLETED BY AUTHORIZED COMPANY OFFICER
REQUEST APPROVED
The statements contained herein are true and correct at
(city),
State of
on the
day of
, 20
FOR THE COMMISSIONER
NO CORPORATE SECURITIES NOW BEING DEPOSITED HAVE BEEN ISSUED BY ANY OF OUR AFFILIATED COMPANIES
BY
Company Officer
Print Name and Title
Deputy Commissioner
Date
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