Get Registration Form - In.gov - In

Completing the Registration Form for captive insurers in Indiana is essential for compliance with state regulations. This guide will walk you through each section of the form to ensure a smooth online submission process.

Follow the steps to complete your Registration Form accurately.

1. Click ‘Get Form’ button to obtain the form and open it in the designated application.
2. Enter the captive insurer name in the appropriate field. Ensure that the name matches the official documentation of the company.
3. Provide the address of the captive insurer. Include the street address, city, state, and zip code to avoid any processing delays.
4. Fill in the Federal Employer Identification Number (FEIN). This number is crucial for identification and taxation purposes.
5. Include a contact telephone number for the registered person or department within the company.
6. Designate a contact person along with their title or position within the company. This information is essential for communication regarding the registration.
7. Provide the contact phone number for the designated contact person to facilitate follow-up if needed.
8. Input the email address of the contact person. This will be used for any electronic communications or notifications.
9. Specify the state of incorporation for the captive insurer. This should reflect the legal state where the company is registered.
10. State the annual direct written premium amount for the company, which is necessary for evaluating the insurer's business operations.
11. Review the certification statement carefully. You are confirming the truthfulness of the information provided.
12. Sign the form in the designated space to certify your assertions under penalties of perjury. Include the typed or printed name of the authorized officer or agent.
13. Fill in the address, phone number, and email address of the authorized officer or agent to ensure proper identification.
14. Prepare the form and the payment check for submission. Ensure that both documents are compiled in accordance to the specified guidelines.
15. Finally, save your changes, download a copy of the completed form, and print it if necessary for your records.

Complete your Registration Form online to ensure compliance with Indiana regulations.