Get Appendix A, Exhibit 1

Filling out the Appendix A, Exhibit 1 form is an essential step for applicants seeking to establish a captive insurance company. This guide will provide you with clear, step-by-step instructions to help you complete the form accurately and efficiently.

Follow the steps to successfully complete the form online.

1. Click the ‘Get Form’ button to access the form and open it in your preferred online editing tool.
2. Begin by filling in the name of the proposed captive in the designated field. Ensure this reflects the intended name of your insurance entity.
3. Indicate the type of proposed captive by selecting one from the list provided: Pure, Association, Industrial Insured, Branch, Sponsored. Make sure to check the relevant option clearly.
4. Specify the form of organization, selecting from Stock, Mutual, Reciprocal, LLC, Non-profit, or Other. If 'Other' is chosen, provide a brief explanation.
5. Enter the date of formation for the captive insurance entity.
6. Provide the Federal Employer Identification Number (FEIN) for the proposed captive.
7. List the parent or beneficial owner followed by the names of all beneficial owners on the next line.
8. Explain the relationship among beneficial owners. This helps clarify the ownership structure.
9. Include a copy of the most recent audited financial statements for the beneficial owners.
10. Fill in the contact details of an individual responsible for this application, including their name, address, telephone number, and email.
11. Detail the names of the officers and directors of the proposed captive insurance company, including roles such as Chairman, President, and Directors.
12. Indicate the location of the principal office for the proposed captive.
13. Provide the location of records and books pertinent to the captive company.
14. Specify the jurisdiction(s) where the majority of risks will be located.
15. Enter details of the resident registered agent and their address.
16. List the initial capital and surplus details, including the amounts contributed by policyholders and other persons.
17. If applicable, provide the name and address of the bank if Letters of Credit will be used.
18. Confirm whether the parent company has prepared resolutions for authorizing establishment of the captive, including designated individuals for voting stock and negotiating agreements.
19. Indicate whether an Audit Committee will be formed by selecting 'Yes' or 'No.'
20. Indicate whether an Executive Committee will be formed by selecting 'Yes' or 'No.'
21. List the names of members on the Investment Committee.
22. Provide the contact details for the Authorized Captive Manager, including name, address, telephone number, and email.
23. List the name, address, telephone number, and email of the Law Firm and Attorney associated with the captive.
24. Provide the name and address of the Claims Handler and Underwriter.
25. List the contact details of the Authorized Certified Public Accountant.
26. Include the name and address of the Authorized Actuary.
27. List the contact details of the Reinsurance Broker/Intermediary.
28. If applicable, upload a statement from the alien captive insurance company granting consent for examination by the Department.
29. Certify the accuracy of your information by providing your name, signature, title, and the date of signing at the end of the form.
30. After completing the form, review your entries for accuracy. You can then save changes, download, print, or share the completed document as needed.

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