Purchasing Groups Notification

This checklist contains items that must be submitted in order to complete the notice and registration requirements for a Purchasing Group intending to do business in New York.

• Registration Form* (See Part A of Circular letter No. 3 Dated 1990)
• Purchasing group’s principal place of business
• The method by which, and the person or persons if any through whom, insurance will be offered to its members whose risks are resident or located in this state
• All other states the group intends to do business
• A certified copy of a resolution by the purchasing group’s governing body or empowered person authorizing the requisite power of attorney
• Certificate of Appointment of Attorney to Accept Service and Designation*
  (See Part B of Circular Letter No. 3 Dated 1990)
• Name, address, and telephone number of contact person of the insurers that provide coverage for the New York members of the purchasing group.
  (Submit this information only if such insurers are licensed in the State of New York)
• In the case where the insurer is unauthorized in New York, provide the name, license number, address, and telephone number of excess line broker
• Registration Fee of $100.00 payable by check to the Superintendent of Financial Services.

* These forms are on the following pages. The completed forms and items on this checklist should be mailed to:

Marina Lutchman
Principal Insurance Examiner
New York State Department of Financial Services
Property Bureau
One State Street, 6th Floor
New York, NY 10004
212-480-5459
Email:

The purchasing group should not conduct or transact business in this state until it has been notified that its registration is complete.

Part A - Purchasing Group Notice and Registration
(PDF Format: "file save" feature requires Acrobat Reader 7.0 or above)

Part B - Appointment of Attorney to Accept Service and Designation
(PDF Format: "file save" feature requires Acrobat Reader 7.0 or above)