If any Rule or portion of a Rule of this Chapter or its applicability to any person or circumstance is held invalid by a court, the remainder of the Chapter or the applicability of the provision to other persons or circumstances shall not be affected. To this end, the provisions of this Chapter are declared severable.

Authority: 2011 Public Acts, Chapter 468, T.C.A. §§ 56-13-101 through 56-13-418, 56-13-108, 56-13- 115, and 56-13-121. Administrative History: Original rule filed November 30, 2012; effective February 28, 2013. Repeal and new rule filed September 22, 2017; effective December 21, 2017. APPENDIX A TENNESSEE CAPTIVE INSURER ANNUAL REPORT As of (date) of the Condition and Affairs of __(Name of Captive Insurance Company)__ Date of License: ______________________________________________________________________ Company Street Address: _______________________________________________________________ Company City, State, Zip Code: __________________________________________________________ Books and Records Street Address: _______________________________________________________ Captive Manager Name: ________________________________________________________________ Captive Manager Street Address: _________________________________________________________ Annual Report Contact Name: ___________________________________________________________ Annual Report Contact Number: __________________________________________________________ Annual Report Contact Email: ____________________________________________________________ Officers: Directors / Managers: President: _______________________ ________________________________________ Secretary: _______________________ ________________________________________ Treasurer: _______________________ ________________________________________ _________: _______________________ ________________________________________ _________: _______________________ ________________________________________ _________: _______________________ ________________________________________ 1. List the name(s) and address(es) of the beneficial owners of the captive and corresponding percentages of ownership: Name Address % Ownership 2. Type of Captive: ❑Pure ❑ Association ❑ Risk Retention Group ❑ Protected Cell ❑ Industrial Insured ❑ Special Purpose 3. Organizational form:_________________________________________________________________ If organized as a stock company, please include a description of all authorized stock classes, whether the class is preferred or common stock, and for each class, the number of shares authorized, shares outstanding, and the par value. 4. Provide the name and address of the Captive Manager. ____________________________________________________________________________________ ____________________________________________________________________________________ Has the Captive Manager changed from the last annual filing? ❑ Yes ❑ No 5. Provide the individual name, firm name and firm address of the Actuary. ____________________________________________________________________________________ ____________________________________________________________________________________ Has the Actuary changed from the last annual filing? ❑ Yes ❑ No (Appendix A, continued) 6. Provide the individual name, firm name and firm address of the Certified Public Accountant. ____________________________________________________________________________________ ____________________________________________________________________________________ Has the Certified Public Accountant changed from the last annual filing? ❑ Yes ❑ No 7. Attach a complete copy of the company’s unaudited financial statements as of prior year end that include the Balance Sheet and Income Statement. 8. Were any changes made to the charter, bylaws or articles since the last annual filing? ❑ Yes ❑ No 9. Did the company provide notification to and receive approval from the Captive Insurance Section for all material transactions? ❑ Yes ❑ No If no, provide a brief description including the dollar amount on a separate attachment. 10. Since the last annual filing, were there any related party transactions? ❑ Yes ❑ No If yes, provide a brief description including the dollar amount on a separate attachment. 11. Have all assets been valued in accordance with GAAP? ❑ Yes ❑ No If other than GAAP was used, please explain: 12. Do the company’s assets include any loans to its parent, affiliates, or unaffiliated companies? ❑ Yes ❑ No If yes, please answer the following: (a) Were any of these loans entered into this year? ❑ Yes ❑ No If yes, what is the date of Captive Insurance Section approval? __________________ (b) Amount of the loan as of the end of the year: _____________________________ (c) Describe the terms of the loan on a separate attachment. (d) Have all interest payments due for the year been collected? ❑ Yes ❑ No If no, when are the interest payments expected? _____________________________ (e) Attach copies of current financial statements of the company or companies to whom loans have been made. 13. Were any of the company’s assets or stock pledged as collateral at any time during the year or did the captive provide any outside guarantees? ❑ Yes ❑ No If yes, please provide the date of Captive Insurance Section approval and a brief description on a separate attachment. 14. Has each officer, director and key employee for the current reporting year filed a disclosure with the captive’s board of directors disclosing any potential conflicts of interest as outlined in the captive’s conflict of interest policy? ❑ Yes ❑ No 15. Have loss and loss adjustment expense (LAE) reserves been discounted? ❑ Yes ❑ No If yes, what interest rate was used? _____________________ 16. Were any dividends paid during the year? ❑ Yes ❑ No If yes, provide the date of approval by the Captive Insurance Section, the date(s) paid and amounts paid. 17. Did the company hold a board of directors meeting in Tennessee during the reporting period as required by Tenn. Code Ann. § 56-13-103(b)? ❑ Yes ❑ No 18. Does the company participate in a reinsurance pooling arrangement? ❑ Yes ❑ No If yes, identify the name of the pool and either the pool’s domicile or the domiciles of the other pool participants. (Appendix A, continued) 19. Did the company write any new lines of business this year? ❑ Yes ❑ No If yes, provide the date of Captive Insurance Section approval and a listing of new lines on a separate attachment. 20. Did the company write premiums this year? ❑ Yes ❑ No If not, does the company plan to write insurance in the next year? ❑ Yes ❑ No If not, does the company plan on going dormant or dissolving in the next year? ❑ Yes, Dormancy ❑ Yes, Dissolving ❑No 21. In the past year were there any material changes in the management's understanding of the company's financial condition or any trends, events or uncertainties that have had or will likely cause the company to substantially deviate from its filed business plan. If yes, please attach an explanatory statement. ❑ Yes ❑ No 22. Please complete the following: EXHIBIT OF PREMIUMS AND LOSSES Premium Schedule 1 2 3 4 5 Direct Reinsurance Reinsurance Net Premiums Lines of Coverage Business Assumed Ceded Written 1. 2. 3. 4. 5. 6. 7. 8. 9. Totals Paid Loss Schedule 1 2 3 4 5 Lines of Coverage Direct Assumed Ceded Net Losses Business Reinsurance Reinsurance Paid 1. 2. 3. 4. 5. 6. 7. 8. 9. Totals (Appendix A, continued) Loss Reserve Schedule 1 2 3 4 5 Lines of Coverage Direct Assumed Ceded Net Loss Business Reinsurance Reinsurance Reserves 1. 2. 3. 4. 5. 6. 7. 8. 9. Totals SCHEDULE OF REINSURANCE Assumed Reinsurance as of Current Year End 1 2 3 4* 5** 6*** Federal ID Name of State or Assumed Assumed Paid Assumed Loss Number Reinsured (include Country of Premiums Losses Reserves pool participants) Domicile 1. 2. 3. 4. 5. 6. 7. 8. 9. Totals * Total for Column 4 must agree to Premium Schedule ** Total for Column 5 must agree to Paid Loss Schedule *** Total for Column 6 must agree to Loss Reserve Schedule Ceded Reinsurance as of Current Year End 1 2 3 4* 5** 6*** Federal ID Name of State or Ceded Ceded Paid Ceded Loss Number Reinsured (include Country of Premiums Losses Reserves pool participants) Domicile 1. 2. 3. 4. 5. 6. 7. 8. 9. Totals * Total for Column 4 must agree to Premium Schedule ** Total for Column 5 must agree to Paid Loss Schedule *** Total for Column 6 must agree to Loss Reserve Schedule (Appendix A, continued) INVESTMENTS OWNED AT CURRENT YEAR END 1 2 3 4 Description Investment Cost Statement Value Type* 1. 2. 3. 4. 5. 6. 7. 8. Totals * Enter the corresponding numbers for the investment type as noted below: 1. Bonds 2. Stocks 3. Cash and Short-Term Investments 4. Loans and Notes Receivable 5. Cash Surrender Value of Life Insurance 6. Letters of Credit 7. Other CERTIFICATION The officers of this company, being duly sworn, each depose and say that they are the described officers of said insurer and attest to the following: (1) that as of the date of this Annual Report (as noted above), the company has maintained the minimum capital and surplus requirements pursuant to Tenn. Code Ann. § 56-13-105. (2) the attached schedules, exhibits, and explanations therein contained, annexed or referred to are a full and true statement, in all material respect of the company’s financial condition and results of operations, according to the best of their information, knowledge, and belief respectively. (3) that pursuant to Tenn. Code Ann. § 56-13-109 and Tenn. Comp. R. & Regs. 0780-01-41-.03, the company ❑will ❑will not (check one) file an independently audited financial report, including an actuarial opinion, with the Tennessee Department of Commerce and Insurance on or before June 30 for the period covered by this Annual Report, or alternative filing date of ________________ as approved by the Department. NOTE: A company that does not annually file independently audited financial reports must be examined at least every three years. Tenn. Code Ann. § 56-13-109. Companies who file independently audited financial reports must be examined at least every five years. Original, sworn, and notarized signatures of two officers are required. Tenn. Code Ann. § 56-13-108. ________________________________________ __________________________________________ Printed Name: ____________________________ Printed Name: ______________________________ Title: ___________________________________ Title: _____________________________________ Subscribed to and sworn before me this ______ day of __________________, ________. __________________________________ (seal) Notary Public Is this an original filing? ❑yes ❑no If no, (Appendix A, continued) 1. State the amendment #: ___________ 2. Date filed: ___________ 3. Number of pages attached: _____________ OVERSIGHT DOCUMENT CHECKLIST Please certify that the following documents are current as filed with the Captive Insurance Section, are new (and attached), or are not applicable at this time for: (Name of Captive Insurance Company) 1. Executed agreement between the captive and the captive manager. ❑ Current as filed ❑ New ❑ N/A 2. Executed agreement with audit firm. ❑ Current as filed ❑ New ❑ N/A 3. Executed agreement with actuarial firm. ❑ Current as filed ❑ New ❑ N/A 4. Sample policy form(s) used by captive. ❑ Current as filed ❑ New ❑ N/A 5. Minutes and resolutions of all board meetings. ❑ Current as filed ❑ New ❑ N/A 6. Executed reinsurance and/or pooling agreements. ❑ Current as filed ❑ New ❑ N/A 7. Statement of Investment Policy. ❑ Current as filed ❑ New ❑ N/A 8. Code of ethics and certificate of acknowledgement by owners. ❑ Current as filed ❑ New ❑ N/A 9. Conflict of interest policy statement and owner’s certificate of acknowledgement. ❑ Current as filed ❑ New ❑ N/A To the best of my knowledge, the above documents have either been filed with the Captive Insurance Section (and no changes have been made), are attached hereto, or are not applicable. ____________________________________ _______________________________ Captive Manager Date