EOED-DOI

Company Name(Required)

Company NAIC Number(Required)

Total Number of Certificates Required(Required)

Date As Listed On The Certificate Of Compliance(Required)

$20.00 non-refundable fee per certificate. Payment can be sent electronically via OPTins or via check made payable to the Commonwealth of Massachusetts.

Total Amount Due

Send certificates to

Name(Required)

First Last

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Person Filling Out This Form(Required)

First Last

Phone(Required)

Email(Required)

Please submit the payment with OPTins or mail the check for the certificate fees to the following address:

Commonwealth of Massachusetts
Division of Insurance
Company Licensing Section
1 Federal Street
Boston, MA 02110