"Application for Recognition - Captive Insurance Company Actuarial Services and Opinions and/Or Loss Reserve/Expense Certification" - Connecticut

Application for Recognition - Captive Insurance Company Actuarial Services and Opinions and/Or Loss Reserve/Expense Certification is a legal document that was released by the Connecticut Insurance Department - a government authority operating within Connecticut.

Form Details:

  • Released on September 1, 2014;
  • The latest edition currently provided by the Connecticut Insurance Department;
  • Ready to use and print;
  • Easy to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of the form by clicking the link below or browse more documents and templates provided by the Connecticut Insurance Department.

ADVERTISEMENT
ADVERTISEMENT

Download "Application for Recognition - Captive Insurance Company Actuarial Services and Opinions and/Or Loss Reserve/Expense Certification" - Connecticut

916 times
Rate (4.6 / 5) 46 votes
STATE OF CONNECTICUT
INSURANCE DEPARTMENT
Application for Recognition:
Captive Insurance Company Actuarial Services & Opinions and/or
Loss Reserve/Expense Certification
INDIVIDUAL BIOGRAPHICAL AFFIDAVIT
(Attach additional pages, as necessary.)
1. Full Legal Name: ___________________________
2. Residence Address: ___________________________________________________
3.
Education: (Please list all educational institutions attended and addresses for each,
including major concentrations and major subjects.)
Academic Institution, Degrees & Dates Conferred:
College or University________________________________________
Graduate or Professional _____________________________________
QUALIFICATIONS: In order to be considered for recognition as an independent actuary and to
sign statements of opinions for a captive insurance company that is acceptable to the Insurance
Commissioner with respect loss and loss adjustment expenses reserves, current and prospective,
the candidate must demonstrate and articulate their qualifications. The following section is
designed to document and describe the qualifications and experiences that uniquely position the
applicant to be determined to be acceptable.
1. Present Chief Occupation:
Position or Title: ____________________________ Length of time: _________
Firm or Employer Name: ________________________________________
Address: ____________________________________________________________
Email Address: ___________________________ Phone: _________________
Time with this firm / employer: _______________
Contact information to be listed on Connecticut Insurance Department website? __
2. In order to be recognized as an independent actuary or to certify property & casualty
losses and loss expenses, sign statements of opinions with respect the accuracy and
appropriateness thereof for a captive insurance company, that is acceptable to the
Insurance Commissioner the candidate must be credentialed in one or more of the
following areas. Please check the applicable box(es) relating to your qualification(s).
09/2014
STATE OF CONNECTICUT
INSURANCE DEPARTMENT
Application for Recognition:
Captive Insurance Company Actuarial Services & Opinions and/or
Loss Reserve/Expense Certification
INDIVIDUAL BIOGRAPHICAL AFFIDAVIT
(Attach additional pages, as necessary.)
1. Full Legal Name: ___________________________
2. Residence Address: ___________________________________________________
3.
Education: (Please list all educational institutions attended and addresses for each,
including major concentrations and major subjects.)
Academic Institution, Degrees & Dates Conferred:
College or University________________________________________
Graduate or Professional _____________________________________
QUALIFICATIONS: In order to be considered for recognition as an independent actuary and to
sign statements of opinions for a captive insurance company that is acceptable to the Insurance
Commissioner with respect loss and loss adjustment expenses reserves, current and prospective,
the candidate must demonstrate and articulate their qualifications. The following section is
designed to document and describe the qualifications and experiences that uniquely position the
applicant to be determined to be acceptable.
1. Present Chief Occupation:
Position or Title: ____________________________ Length of time: _________
Firm or Employer Name: ________________________________________
Address: ____________________________________________________________
Email Address: ___________________________ Phone: _________________
Time with this firm / employer: _______________
Contact information to be listed on Connecticut Insurance Department website? __
2. In order to be recognized as an independent actuary or to certify property & casualty
losses and loss expenses, sign statements of opinions with respect the accuracy and
appropriateness thereof for a captive insurance company, that is acceptable to the
Insurance Commissioner the candidate must be credentialed in one or more of the
following areas. Please check the applicable box(es) relating to your qualification(s).
09/2014
A member in good standing of the Casualty Actuarial Society and five years of
property and casualty loss and loss expense reserve experience. Include a copy
of certificate or diploma.
A member in good standing of the American Academy of Actuaries and five
years of property and casualty loss and loss expense reserve evaluation
experience. Include a copy of certificate of diploma.
A property & casualty loss reserve specialist with at least ten years of experience,
five (5) of which shall have included responsibility for:
-
Overall loss/claim reserve levels or a significant portion of overall loss
reserve levels; or
-
Certification of overall loss/claim reserves or a significant portion of
overall reserves; or
-
Prospective evaluation of the reasonableness of the overall reserves or a
significant portion of the overall reserves.
3. Indicate which actuarial exams completed, if not a Fellow:
4.
Membership in Professional Societies or Associations (please provide verification of
the membership):
5.
Describe relevant Property & Casualty and/or Life & Health loss reserve experience:
6. Additional Significant and Relevant Experience, positions, or titles held:
7. Describe your firm in terms of its history, business size, portfolio of clients, lines of
business:
09/2014
8. List the current captive insurance programs that you have experience with and indicate
which Connecticut captive program(s) you intend to be certifying:
9.
Have you ever been subject to a regulatory reprimand or disciplinary action, refused
admission or approval or lost any license as a result of professional activities?
If “Yes”, please explain.
Yes
No
10. Attach a complete resume or CV.
11. Please provide two (2) professional references, with appropriate contact information:
I hereby certify that my responses to the above are true and complete, and I have read and
understand the requirements and provisions of the General Statutes of Connecticut, Chapter 698,
§38a - 91 et seq., pertaining to captive insurers, and will fully comply with the laws and
regulations of the State of Connecticut.
(NO FEE REQUIRED)
Signed_________________________________
Dated _________________________________
Subscribed and sworn to before me this _____ day of ___________________, 20_____.
Signature of Notary Public __________________________________________
Notary Seal
Notary Public authorized by the law of the State of ________________
to administer oaths. My commission expires on _________________
09/2014
Page of 3