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- Form MO375-0596 "Application for Authorization as an Independent Certified Public Accountant for Captive Insurance Business" - Missouri
Form MO375-0596 "Application for Authorization as an Independent Certified Public Accountant for Captive Insurance Business" - Missouri
Download Form MO375-0596 "Application for Authorization as an Independent Certified Public Accountant for Captive Insurance Business" - Missouri
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2MISSOURI DEPARTMENT OF COMMERCE AND INSURANCE
APPLICATION FOR AUTHORIZATION AS AN INDEPENDENT CERTIFIED PUBLIC ACCOUNTANT
FOR CAPTIVE INSURANCE BUSINESS
To the Director of Commerce and Insurance, Jefferson City, Missouri, I hereby apply for authorization as an independent certified public
accountant for the transacting of audits for Captive Insurance Companies.
ONLY INDIVIDUALS MAY APPLY
1. FULL LEGAL NAME
2. RESIDENCE ADDRESS
3. (A) DATE OF BIRTH
4. EDUCATION AND DEGREE
HIGH SCHOOL
COLLEGE
GRADUATE OR PROFESSIONAL
5. LIST ALL INSURANCE AND/OR CAPTIVE AUDITING EXPERIENCE FOR PAST 15 YEARS INCLUDING SPECIFIC DATES (ATTACH ADDITIONAL SHEETS AS NECESSARY)
6. LIST THE MISSOURI CAPTIVE ACCOUNT(S) YOU WILL BE AUDITING.
7. PRESENT CHIEF OCCUPATION
POSITION OR TITLE
HOW LONG?
EMPLOYER NAME
HOW LONG WITH THIS EMPLOYER?
ADDRESS
BUSINESS TELEPHONE
BUSINESS E-MAIL
8. HAS APPLICANT EVER BEEN ARRESTED, OR INDICTED FOR AND/OR CONVICTED OF ANY CRIME OR OFFENSE OTHER THAN A TRAFFIC VIOLATION?
NO
YES (attach full particulars of each case and disposition thereof)
9. I CONTROL DIRECTLY OR INDIRECTLY, OR OWN LEGALLY OR BENEFICIALLY THE OUTSTANDING STOCK OF THE FOLLOWING INSURERS
10. DO YOU CURRENTLY HOLD OR HAVE YOU HELD ANY TYPE OF INSURANCE LICENSE?
NO
YES
If yes, complete the following:
TYPE
STATE
EXPIRATION DATE
11. HAVE YOU EVER HAD A LICENSE OR PRIVILEGE REFUSED OR REVOKED BY AN INSURANCE DEPARTMENT?
NO
YES
If so, give details: _______________________________________________________________________________________________
_______________________________________________________________________________________________________________
MO 375-0596 (5-2020)
MISSOURI DEPARTMENT OF COMMERCE AND INSURANCE
APPLICATION FOR AUTHORIZATION AS AN INDEPENDENT CERTIFIED PUBLIC ACCOUNTANT
FOR CAPTIVE INSURANCE BUSINESS
To the Director of Commerce and Insurance, Jefferson City, Missouri, I hereby apply for authorization as an independent certified public
accountant for the transacting of audits for Captive Insurance Companies.
ONLY INDIVIDUALS MAY APPLY
1. FULL LEGAL NAME
2. RESIDENCE ADDRESS
3. (A) DATE OF BIRTH
4. EDUCATION AND DEGREE
HIGH SCHOOL
COLLEGE
GRADUATE OR PROFESSIONAL
5. LIST ALL INSURANCE AND/OR CAPTIVE AUDITING EXPERIENCE FOR PAST 15 YEARS INCLUDING SPECIFIC DATES (ATTACH ADDITIONAL SHEETS AS NECESSARY)
6. LIST THE MISSOURI CAPTIVE ACCOUNT(S) YOU WILL BE AUDITING.
7. PRESENT CHIEF OCCUPATION
POSITION OR TITLE
HOW LONG?
EMPLOYER NAME
HOW LONG WITH THIS EMPLOYER?
ADDRESS
BUSINESS TELEPHONE
BUSINESS E-MAIL
8. HAS APPLICANT EVER BEEN ARRESTED, OR INDICTED FOR AND/OR CONVICTED OF ANY CRIME OR OFFENSE OTHER THAN A TRAFFIC VIOLATION?
NO
YES (attach full particulars of each case and disposition thereof)
9. I CONTROL DIRECTLY OR INDIRECTLY, OR OWN LEGALLY OR BENEFICIALLY THE OUTSTANDING STOCK OF THE FOLLOWING INSURERS
10. DO YOU CURRENTLY HOLD OR HAVE YOU HELD ANY TYPE OF INSURANCE LICENSE?
NO
YES
If yes, complete the following:
TYPE
STATE
EXPIRATION DATE
11. HAVE YOU EVER HAD A LICENSE OR PRIVILEGE REFUSED OR REVOKED BY AN INSURANCE DEPARTMENT?
NO
YES
If so, give details: _______________________________________________________________________________________________
_______________________________________________________________________________________________________________
MO 375-0596 (5-2020)
12. ARE YOU CURRENTLY LICENSED AS A CPA?
NO
YES
If yes, in the state of: ___________________________________
13. HAS YOUR LICENSE AS A CPA IN THIS STATE OR ANY STATE EVER BEEN SUSPENDED OR REVOKED?
NO
YES
If so, give details: _______________________________________________________________________________________________
14. WILL YOU ASSIGN ONLY INDIVIDUALS THAT HAVE A MINIMUM OF TWO YEARS INSURANCE AUDITING EXPERIENCE?
NO
YES
I hereby certify that I have read and understand all of the requirements and provisions of the Captive Insurance Financial Regulation relating
to Captive Insurance Companies, and will fully comply therewith. (NO FEE REQUIRED)
SIGNATURE
DATE
NOTARY
NOTARY PUBLIC EMBOSSER OR
STATE
COUNTY (OR CITY OF ST. LOUIS)
BLACK INK RUBBER STAMP SEAL
SUBSCRIBED AND SWORN BEFORE ME, THIS
USE RUBBER STAMP IN CLEAR AREA BELOW.
DAY OF
YEAR
NOTARY PUBLIC SIGNATURE
MY COMMISSION
EXPIRES
NOTARY PUBLIC NAME (TYPED OR PRINTED)
MO 375-0596 (5-2020)
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DA Form 2062 "Hand Receipt/Annex Number"
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DD Form 2813
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DD Form 2977 "Deliberate Risk Assessment Worksheet"
-
DA Form 31 "Request and Authority for Leave"
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AF Form 910 "Enlisted Performance Report (AB Thru Tsgt)"
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DD Form 1750 "Packing List"
-
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-
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- USCIS Form I-797C, Notice of Action USCIS Form I-797C, Notice of Action
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