State Guaranty Association Member Company Contact Information

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Welcome to the State Life and Health Insurance Guaranty Association member company address update portal. Please use this form to report assessment mailing contacts and proxy/annual meeting notice contacts to the participating state life and health insurance guaranty associations shown below. Address/contact information for up to five group companies can be submitted on this form; if you are reporting updates for more than five companies please complete additional forms as necessary.

All fields marked with an asterisk (*) must be completed.

  1. Please check the state life and health insurance guaranty association(s) where the company is a member and that this address and/or contact information should be forwarded to. Only select the state guaranty associations where your company is a member.
    Click here to select all participating state guaranty associations, and then uncheck any state guaranty associations where the company/companies are not members.
    Alabama
    Alaska
    Arizona
    Arkansas
    California
    Colorado
    Connecticut
    Delaware
    District of Columbia
    Florida
    Georgia
    Hawaii
    Idaho
    Illinois
    Indiana
    Iowa
    Kentucky
    Louisiana
    Maine
    Maryland
    Massachusetts
    Michigan
    Minnesota
    Mississippi
    Missouri
    Montana
    Nebraska
    Nevada
    New Hampshire
    New Jersey
    New Mexico
    New York
    North Carolina
    North Dakota
    Ohio
    Oklahoma
    Oregon
    Pennsylvania
    Rhode Island
    South Carolina
    South Dakota
    Tennessee
    Texas
    Utah
    Vermont
    Virginia
    Washington
    West Virginia
    Wisconsin
    Wyoming
    NOTE: If a state life and health insurance guaranty association is selected to which your company is not a member, such selection will be deemed invalid. Such invalid selection shall not be construed as providing membership status in such state guaranty association.
    The following state life and health insurance guaranty associations are not participating in this electronic portal, please contact these guaranty associations directly regarding contact updates.
    Kansas LHIGA - tlangland@kslifega.org
  2. Please enter the NAIC Number/Company Code and Company Name
    Company 1:
    NAIC Company Code *
    Company Name *
    Company 2:
    NAIC Company Code
    Company Name
    Company 3:
    NAIC Company Code
    Company Name
    Company 4:
    NAIC Company Code
    Company Name
    Company 5:
    NAIC Company Code
    Company Name

  3. Please note, not all participating life and health insurance guaranty associations are able to store multiple contacts for each member company; those guaranty associations that can only store one contact will use the Assessment Mailing Contact for all mailings.
  4. Please enter the Assessment Mailing Contact for the company(ies) entered above.
    Assessment Contact Department *
    Assessment Mailing Address Street *
    City *
    State *
    Zip * Format: 12345-6789
    Assessment Contact E-mail Address *
    Assessment Contact Direct Telephone Number * Format: 123-456-7890
    Assessment Contact Fax Number Format: 123-456-7890
  5. Please enter the Proxy or Annual Meeting Notice Mailing Contact for the company(ies) entered above.
    Check this box if the Proxy or Annual Meeting Notice Mailing Contact is the same as the Assessment Mailing Contact entered above.
    Proxy Contact Department *
    Proxy Mailing Address Street *
    City *
    State *
    Zip * Format: 12345-6789
    Proxy Contact Email Address *
    Proxy Contact Direct Telephone Number * Format: 123-456-7890
    Proxy Contact Fax Number Format: 123-456-7890
  6. Please enter the Premium Tax Offset Report Distribution Contact for the company(ies) entered above. The Premium Tax Offset Report Distribution Contact information will be used only for the distribution of the annual premium tax offset reports by those state guaranty associations that generate the reports for past member assessments paid for filing with the state premium tax returns.
    Check this box if the Premium Tax Offset Report Distribution Contact is the same as the Assessment Mailing Contact entered above.
    Premium Tax Offset Report Distribution Contact Department *
    Premium Tax Offset Report Distribution Mailing Address Street *
    City *
    State *
    Zip * Format: 12345-6789
    Premium Tax Offset Report Distribution Contact Email Address *
    Premium Tax Offset Report Distribution Contact Direct Telephone Number * Format: 123-456-7890
    Premium Tax Offset Report Distribution Contact Fax Number Format: 123-456-7890
This Form was completed by: (name and email address)
Name *
Email Address *
If you have any questions regarding how to properly complete this form, please send a detailed question to datacollectionform@nolhga.com