Form AIS-R "Annual Information Statement (Reciprocal Insurer)" - California

What Is Form AIS-R?

This is a legal form that was released by the California Department of Insurance - a government authority operating within California. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on March 1, 2020;
  • The latest edition provided by the California Department of Insurance;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form AIS-R by clicking the link below or browse more documents and templates provided by the California Department of Insurance.

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Download Form AIS-R "Annual Information Statement (Reciprocal Insurer)" - California

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STATE OF CALIFORNIA – DEPARTMENT OF INSURANCE
ANNUAL INFORMATION STATEMENT (RECIPROCAL INSURER)
AIS-R (Rev. 10/2021)
The answers on this statement must reflect any pertinent changes during the past calendar year. Those not
previously submitted to and approved by the California Insurance Commissioner require immediate
submission.
Answer completely and accurately.
For Period Covering January 1 - December 31, _____
1. Name of Company: ______________________________________________________________
a. Statutory Home Office Address:
________________________________ ____________
Street (No P.O. Box)
Suite
________________________________ ____________ ___________
City
State
Zip Code
Check if the state of domicile is different from California Certificate of Authority.
A checked box requires an amendment to the California Certificate of Authority. The
California form and process for redomestication can be accessed on the
Amended
Certificate of Authority
web page.
b. Mailing Address (All mailings from the Department will go to this address):
________________________________ ___________
Street or P.O. Box
Suite
________________________________ ____________ ___________
City
State
Zip Code
Check if different from last year. Date moved:
____________________
2.
Agent for Service of Process per Insurance Code §§1600-1604 is:
(Confirm the following data with your appointed agent.)
Name: ________________________________ Telephone: ____________________
Individual Name (No Company/Corporation Name)
________________________________ ____________
Street (No P.O. Box)
Suite
________________________________ ____________ ___________
City
State
Zip Code
Check if the address is different from last year. Date moved:
____________________
Inform your Agent for Service of Process that he must notify the Department of Insurance of
change of address. Agent must be a California resident.
Is the agent newly appointed during the year?
Yes
No
If yes, have you sent in a new
Appointment of Agent for Service of Process
form and the filing
fee?
Yes
No
For the current fee, please see the "Appointment of agent for service of process" fee category on
the
Schedule of Fees and Charges
web page.
3. Does the reciprocal insurer (Exchange) issue nonassessable policies in any jurisdiction?
Yes
No
a. Has the Exchange obtained from the California Insurance Commissioner a Certificate of
Perpetual Nonassessability, per California Insurance Code §1401.5?
Yes
No
If yes, disregard the remaining subsections of this question.
b. Has the Exchange obtained from the California Insurance Commissioner a Certificate of
Capability to Reinsure, per California Insurance Code §1401.5?
Yes
No
If no, does the Exchange act as a reinsurer of risks located in any jurisdiction?
Yes
No
c. Has the Exchange obtained from the California Insurance Commissioner an unrevoked
Certificate of Surplus, per California Insurance Code §1401, permitting it to issue
nonassessable policies?
Yes
No
1 of 4
STATE OF CALIFORNIA – DEPARTMENT OF INSURANCE
ANNUAL INFORMATION STATEMENT (RECIPROCAL INSURER)
AIS-R (Rev. 10/2021)
The answers on this statement must reflect any pertinent changes during the past calendar year. Those not
previously submitted to and approved by the California Insurance Commissioner require immediate
submission.
Answer completely and accurately.
For Period Covering January 1 - December 31, _____
1. Name of Company: ______________________________________________________________
a. Statutory Home Office Address:
________________________________ ____________
Street (No P.O. Box)
Suite
________________________________ ____________ ___________
City
State
Zip Code
Check if the state of domicile is different from California Certificate of Authority.
A checked box requires an amendment to the California Certificate of Authority. The
California form and process for redomestication can be accessed on the
Amended
Certificate of Authority
web page.
b. Mailing Address (All mailings from the Department will go to this address):
________________________________ ___________
Street or P.O. Box
Suite
________________________________ ____________ ___________
City
State
Zip Code
Check if different from last year. Date moved:
____________________
2.
Agent for Service of Process per Insurance Code §§1600-1604 is:
(Confirm the following data with your appointed agent.)
Name: ________________________________ Telephone: ____________________
Individual Name (No Company/Corporation Name)
________________________________ ____________
Street (No P.O. Box)
Suite
________________________________ ____________ ___________
City
State
Zip Code
Check if the address is different from last year. Date moved:
____________________
Inform your Agent for Service of Process that he must notify the Department of Insurance of
change of address. Agent must be a California resident.
Is the agent newly appointed during the year?
Yes
No
If yes, have you sent in a new
Appointment of Agent for Service of Process
form and the filing
fee?
Yes
No
For the current fee, please see the "Appointment of agent for service of process" fee category on
the
Schedule of Fees and Charges
web page.
3. Does the reciprocal insurer (Exchange) issue nonassessable policies in any jurisdiction?
Yes
No
a. Has the Exchange obtained from the California Insurance Commissioner a Certificate of
Perpetual Nonassessability, per California Insurance Code §1401.5?
Yes
No
If yes, disregard the remaining subsections of this question.
b. Has the Exchange obtained from the California Insurance Commissioner a Certificate of
Capability to Reinsure, per California Insurance Code §1401.5?
Yes
No
If no, does the Exchange act as a reinsurer of risks located in any jurisdiction?
Yes
No
c. Has the Exchange obtained from the California Insurance Commissioner an unrevoked
Certificate of Surplus, per California Insurance Code §1401, permitting it to issue
nonassessable policies?
Yes
No
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STATE OF CALIFORNIA – DEPARTMENT OF INSURANCE
ANNUAL INFORMATION STATEMENT (RECIPROCAL INSURER)
AIS-R (Rev. 10/2021)
If yes, disregard subsection (d) of this question.
d. Does the Exchange transact liability, common carrier liability or workers' compensation
insurance in California?
Yes
No
4. What classes of insurance as defined in the California Insurance Code Sections 100-120, other
than those for which the Exchange is now licensed in California, does the Exchange transact in
any jurisdiction? List the classes according to California Insurance Code Sections 100-120.
5. Has there been any change since last June 30 in the Power of Attorney form executed by such
subscribers?
Yes
No
If yes, have the amendments thereto or has the new form, as the case may be, verified by the
Attorney-in-Fact, been filed with this Department?
Yes
No
If no, explain the substance thereof and file with this Department a copy which has been verified
by the Attorney-in-Fact pursuant to California Insurance Code §1320(a).
6. Is it your practice in every instance to require the actual signature of each and every subscriber to
the power of attorney of the Attorney-in-Fact before a policy is issued?
Yes
No
7. Has there been an amendment to the Exchange's Rules and Regulations since the Rules and
Regulations (including any amendments thereto) were last filed with the California Insurance
Commissioner?
Yes
No
If yes and the Amendment has not been so filed, attach a copy of the Amendment (which has been
verified by the secretary of the Exchange's Board of Governors or equivalent governing body).
8. Has there been an amendment to the Charter or Articles of Incorporation of the Attorney-in-Fact, if
a corporation, since the Charter or Articles of Incorporation (including any amendments thereto)
were last filed with the California Insurance Commissioner?
Yes
No
If yes and the Amendment has not been so filed, attach a copy of the Amendment (which has been
certified by the custodian of such document in the Attorney-in-Fact's state of domicile) and the
filing fee. For the current fee, please see the "Amendments to Articles of Incorporation" fee
category on the
Schedule of Fees and Charges
web page.
9. If your Exchange transacts workers' compensation or disability insurance, have the forms of
applications for such insurance and the form of each policy, rider and endorsement providing such
insurance coverage now being used in the Exchange, together with rates, and every amendment to
such forms, verified by the Attorney-in-Fact pursuant to California Insurance Code §§1320(b) and
(c), been filed with this Department?
Yes
No
If no, verify and file in triplicate each such form not heretofore filed. In addition, workers'
compensation forms must be submitted in the usual manner to the Workers' Compensation
Insurance Rating Bureau for preliminary inspection and transmittal to the Commissioner.
10. Conflicts of Interest
Without having first obtained the written consent of the California Insurance Commissioner, has
any person having authority in the management of the Reciprocal's funds or any officer, director,
or trustee of the Reciprocal or of its Attorney-in-Fact (or, if the Attorney-in-Fact consists of one or
more individuals, any such individual): (a) received any money or valuable thing for negotiating,
procuring, recommending or aiding in any loan from the Reciprocal or any purchase by or sale to
the Reciprocal of any real or personal (tangible or intangible) property, (b) had any pecuniary
interest as principal, coprincipal, agent, attorney or beneficiary in any such loan, purchase or sale,
or (c) directly or indirectly purchased, or been pecuniarily interested in the purchase of any of the
assets of the Reciprocal? As used herein, the word "person" includes the Attorney-in-Fact. As
used herein, the word "property" also includes leases and management, investment and/or
administrative service agreements.
Yes
No
If yes, explain in detail and attach all contractual arrangements.
If the California Insurance Commissioner's prior written consent was obtained to the transaction
and/or contractual arrangement, have there been, in the interim, any changes, modifications or
2 of 4
STATE OF CALIFORNIA – DEPARTMENT OF INSURANCE
ANNUAL INFORMATION STATEMENT (RECIPROCAL INSURER)
AIS-R (Rev. 10/2021)
amendments in either the terms or compensation without having first obtained the California
Insurance Commissioner's written consent to the changes, modifications or amendments?
Yes
No
If yes, explain the changes noting any contact made with the Department with respect thereto and
attach copies thereof.
11. Transfer of Property or Business (Merger/Reinsurance Ceded)
Without having first obtained the written consent of the California Insurance Commissioner, has
the Exchange transferred, or attempted to transfer, its entire property or business to any other
person or entered into any transaction the effect of which is: (a) to merge or consolidate its
business in or with another person, whether or not admitted to California, or (b) to reinsure
substantially all of its insurance business in force with any other person, whether or not admitted to
California? As used herein, the word "substantially" means 75% or more. The word "person"
includes all legal entities.
Yes
No
If yes, explain in detail and attach all contractual arrangements.
12. Reinsurance Assumed
Has the Exchange reinsured or assumed substantially all of the insurance business in force of any
other exchange, insurer, fraternal benefit society or grants and annuities society, whether or not
admitted to California?
Yes
No
If yes, explain in detail noting name of cedent and any prior contact with the Department; attach
copies of all contractual arrangements and, if applicable, assumption certificates.
13. Servicing Insurance Contracts
Without obtaining the written consent of the California Insurance Commissioner, has the
Exchange (or its Attorney-in-Fact on behalf thereof) entered into any agreement or arrangement
with any insurer or other exchange not admitted to California (or a management company
affiliated with a non-admitted insurer or exchange) providing for the non-admitted entity to service
(e.g., adjust or pay losses, collect premiums, issue policies or arrange reinsurance, etc.) insurance
contracts entered into in California or issued for delivery in California?
Yes
No
If yes, explain details noting any prior contact made with the Department and attach copies of all
contractual arrangements.
14. Management Contracts
Without having obtained the California Insurance Commissioner's written consent thereto, have
any of the terms (including the compensation) been changed in the most recent Department-
approved management contract the Attorney-in-Fact has with or on behalf of the Exchange?
Yes
No
If yes, explain in detail the changes and attach a copy of the original contract and all of the
amendments or the new contract, as the case may be.
15. Is your Attorney-in-Fact bond continuous in form and now in full force and effect?
Yes
No
If no, has it been renewed to cover the entire ensuing license fee period commencing July 1 of the
year this paper is dated and ending July 1 of the next year?
Yes
No
If no, evidence of such renewal issued by the surety or sureties thereon must be filed with this
Department.
I hereby declare under the penalty of perjury under the laws of the State of California that the foregoing
answers are true and correct.
By:
______________________________
Signature
(Corporate seal)
Name: ______________________________
Title:
______________________________
Date:
______________________________
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STATE OF CALIFORNIA – DEPARTMENT OF INSURANCE
ANNUAL INFORMATION STATEMENT (RECIPROCAL INSURER)
AIS-R (Rev. 10/2021)
Name of person who filled out this Statement:
______________________________
(Print)
______________________________
(Title)
______________________________
(Date)
Enter toll free number, otherwise collect call must be accepted.
Telephone Number: ____________________
Email: ______________________________
Return to:
State of California
Department of Insurance
Corporate Affairs Bureau
1901 Harrison Street, 6th Floor
Oakland, CA 94612
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