23 CAR pt. 29, Appendix A. Captive Insurance Company Application Form

1 State of Arkansas Department of Insurance CAPTIVE INSURANCE COMPANY APPLICATION FORM SECTION A: GENERAL INFORMATION 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 __________________________ 2 Address _____________________________ E-Mail _____________________________ ____________________________________ 4. Indicate Type of Proposed Captive (Please check one): a. __Pure c. __Association e. __Industrial Insured b. __Branch d. __Sponsored 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_______________________________ 3 SECTION B: FINANCIAL INFORMATION 1. Capitalization (if Stock Company) a. Amount of Paid-In Capital $___________________________ b. Type(s) of Stocks to be Authorized Number of Shares (1)_______________________ ____________________________ (2)_______________________ ____________________________ c. Par Value of Each Share by Type Selling Price (1)$______________________ $___________________________ (2)$______________________ $___________________________ 2. Funding (if Mutual or Reciprocal Company) Amount of Contributed Surplus to Policyholders $___________________________ 3. If Letter(s) of Credit Is (Are) Used for Capitalizing/Funding Captive, Please Provide the Following (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 __________________________ 4. Capital and/or Surplus of Captive a. Initial Capital $_____________________________ Initial Surplus $_____________________________ Total $___________________________________ b. Location of Certificates for Shares of Stock ________________________________________________________________________ ________________________________________________________________________ 5. Name(s) and Address(es) of Beneficial Owners Percent of Ownership 4 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_____________________ 5 ____________________________________ Contact Person______________ 5. Name and Address of Actuary, If Applicable Name_______________________________ Telephone__________________ Address_____________________________ E-Mail_____________________ ___________________________________ Contact Person______________ 6. Name and Address of (Re)insurance Broker, If Applicable Name_______________________________ Telephone__________________ Address_____________________________ E-Mail_____________________ ___________________________________ Contact Person______________ 7. If Applicant is an Industrial Insured Captive, please answer the following: 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 _______________ SECTION D: MISCELLANEOUS INFORMATION AND ATTACHMENTS 1. Please include the following information with this Application: 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. 6 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. SECTION E: CERTIFICATION 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) 7 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 _____________________