23 CAR pt. 29, Appendix A
1. Name of Proposed Captive _____
2. Name(s) of Parent(s) or Sponsor(s) of Proposed Captive _____
a. Net Worth of Parent(s)/Sponsor(s) $ _____
b. Name(s) and Address of Proposed Parent(s)
Name _____
Address _____
Telephone _____
E-Mail _____
Name _____
Address _____
Telephone _____
E-Mail _____
c. Please Explain the Relationship Among the Parents (Attach additional sheets, if necessary):
3. Name, address, and phone number of individual to be contacted regarding this application:
Name _____
Telephone _____
Address _______
E-Mail _______
4. Indicate Type of Proposed Captive (Please check one):
a. ☐ Pure b. ☐ Branch c. ☐ Association d. ☐ Sponsored e. ☐ Industrial Insured f. ☐ Producer Reinsurance
5. Organization Form for Proposed Captive (Please check one):
a. ☐ Stock b. ☐ Mutual c. ☐ Reciprocal
6. Principal Office/Place of Business of Proposed Captive:
7. Name and Address of Registered Agent For Service of Process:
Name _______
Telephone _______
Address _______
Email _______
Cell Phone/Pager _______
8. Location of Books and Records of Proposed Captive:
9. Names of Directors of Proposed Captive:
(Biographical Affidavits Must be Provided for each Director. Use the Arkansas Biographical Affidavit form.)
10. Names of Officers of the Proposed Captive:
(Please use a separate sheet, if necessary, to list all officers of the proposed captive. Biographical affidavits must be furnished for all officers. Use the Arkansas Biographical Affidavit form.)
President _______
Vice President _______
Secretary _______
Treasurer _______
a. Amount of Paid-In Capital $ ___
b. Type(s) of Stocks to be Authorized Number of Shares
c. Par Value of Each Share by Type Selling Price
Amount of Contributed Surplus to Policyholders $ ___
(Please use additional sheet(s), if necessary. Arkansas Line of Credit form must be furnished with this Application):
a. Type(s) of Letter(s) of Credit: __ Amount(s): $ __
b. Name and Address of Bank ___
c. Issued in Favor of ___
a. Initial Capital $ ___
Initial Surplus $ ___
Total $ ___
b. Location of Certificates for Shares of Stock
Percent of Ownership
a. ____ ______
b. ____ ______
c. ____ ______
d. ____ ______
6. Explain Relationship Among Beneficial Owners
SECTION C: SERVICE PROVIDERS
1. Name and Address of Management Firm, If Applicable
Name ____ Telephone ___ Address __ E-Mail __ __ Contact Person _____
2. Name and Address of Attorney, If Applicable
Name ____ Telephone ___ Address __ E-Mail __ __ Contact Person _____
3. Name and Address of Claims Administrator, If Applicable
Name ____ Telephone ___ Address __ E-Mail __ __ Contact Person _____
4. Name and Address of Certified Public Accountant, If Applicable
Name ____ Telephone ___ Address __ E-Mail _____
Contact Person
Name Telephone
Address E-Mail
Contact Person
Name Telephone
Address E-Mail
Contact Person
a. Name and address of each full-time employee acting as an Insurance Manager or Buyer
b. Aggregate annual premium $
c. Number of full-time employees
a. An explanation of insurance coverage/limits/reinsurance. (Format attached) b. A certified copy of the captive charter, certificate of incorporation, articles of incorporation and bylaws or, if being formed as a reciprocal, a certified copy of the power of attorney-in-fact and subscription agreement. Certified copies of these documents must be filed before a license is issued. c. A non-refundable fee of $200. d. A feasibility study prepared by a qualified, independent actuary. e. Statement of public benefit to State of Arkansas, to be certified by the Commissioner of Insurance. f. Biographical affidavits for all officers and directors. g. If applicant is an Association Captive, please give history, purpose, size and other details of parent association. h. List all other providers and their responsibilities together with how fees for services rendered are to be charged.
i. If applicant is to be formed as a Reciprocal Captive, applicant must provide, for the Commissioner's approval, its coverages, deductibles, coverage limits, and rates.
j. If applicant is a Sponsored Captive, applicant must provide all contracts between the Sponsored Captive and any of its participants.
k. Statement under oath of its president and secretary, or attorney if formed as a reciprocal, showing its financial condition.
l. An applicant producer reinsurance captive or sponsored captive shall also file:
(1) A business plan demonstrating how the applicant will account for the loss and expense experience of each protected cell at a level of detail found to be sufficient by the commissioner, and how it will report the experience to the commissioner; (2) A statement acknowledging that all financial records of the captive insurance company, including records pertaining to any protected cells, must be made available for inspection or examination by the commissioner; and (3) Evidence that expenses will be allocated to each protected cell in an equitable manner.
m. A detailed Plan of Operation with supporting data including:
(1) Risks to be insured-direct, assumed, and ceded-by line of business; (2) Fronting company if operating as a reinsurer; (3) Expected net annual premium income; (4) Maximum retained risk (per loss and annual aggregate); (5) Rating program; (6) Reinsurance program; (7) Organization and responsibility for loss prevention and safety including the main procedures followed and steps taken to deal with events prior to possible claims; (8) Loss experience for past three years (if applicable) together with projections for the ensuing three years; (9) Organizational chart; and (10) Financial projections on an expected and worse case scenario, certified by the president and secretary of the applicant.
Items (a) through (m) above should be submitted in a three-ring notebook with numbered and lettered tabs [i.e., A.1(a), A.1(b)] with the required information immediately following each tab. Items 1, 3, 4, and 10 above should be projected for a three-year period. NOTE: Prepare one extra copy of all documents required by this application.
n. Annual Report of Parent.
o. 10K or Personal Financial Statements of Owners.
I certify that the information given in this application is true and correct and that all estimates given are true estimates based upon facts which have been carefully considered and assessed.
Name
Date
Signature
(Authorized Officer)
Subscribed and sworn to before me this ___ day of __, 20.
Signature of Notary Public_______
NOTARY SEAL Notary Public authorized by law of the State of __ to administer oaths. My commission expires on __