"Application for Recognition - Captive Insurance Company Manager" - Connecticut

Application for Recognition - Captive Insurance Company Manager is a legal document that was released by the Connecticut Insurance Department - a government authority operating within Connecticut.

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STATE OF CONNECTICUT
INSURANCE DEPARTMENT
Application for Recognition:
Captive Insurance Company Manager
(Attach additional pages, as necessary.)
Applicant Information:
1. Name of captive insurance management firm:_____________________________________
2. Business Address: ____________________________________
____________________________________
____________________________________
3.
Captive insurance management firm authorized representative:
a. Name:
b. Telephone:
c. FAX Number:
d. Email Address:
4. Applicant captive management firm formed as:
a. Corporation
b. Partnership
c. Limited Liability Company (LLC)
d. Other
Date of incorporation:________________________________________________
Place of incorporation or formation: ____________________________________
5. During the past five years, has the Applicant operated under a different name; purchased,
consolidated or merged with any other business or been purchased?
____ Yes ____ No
If Yes, please explain:
6.
Provide the address where the captive management services will be performed, if different
from #2 above.
Captive Management Company Profile
7. Names and titles of key staff:
a. Directors:
b. Principals / Partners:
c. Officers:
d. Managers:
www.ct.gov/cid
P.O. Box 816 Hartford, CT 06142-0816
An Equal Opportunity Employer
STATE OF CONNECTICUT
INSURANCE DEPARTMENT
Application for Recognition:
Captive Insurance Company Manager
(Attach additional pages, as necessary.)
Applicant Information:
1. Name of captive insurance management firm:_____________________________________
2. Business Address: ____________________________________
____________________________________
____________________________________
3.
Captive insurance management firm authorized representative:
a. Name:
b. Telephone:
c. FAX Number:
d. Email Address:
4. Applicant captive management firm formed as:
a. Corporation
b. Partnership
c. Limited Liability Company (LLC)
d. Other
Date of incorporation:________________________________________________
Place of incorporation or formation: ____________________________________
5. During the past five years, has the Applicant operated under a different name; purchased,
consolidated or merged with any other business or been purchased?
____ Yes ____ No
If Yes, please explain:
6.
Provide the address where the captive management services will be performed, if different
from #2 above.
Captive Management Company Profile
7. Names and titles of key staff:
a. Directors:
b. Principals / Partners:
c. Officers:
d. Managers:
www.ct.gov/cid
P.O. Box 816 Hartford, CT 06142-0816
An Equal Opportunity Employer
Indicate which individuals are owners.
Please complete a BIOGRAPHICAL AFFIDAVIT for each.
8. Number of current captive insurance companies under management:
a. Pure: ________
b. Association / Group: _________
c. Special Purpose Vehicles: _________
d. Risk Retention Group: __________
9. List domiciles where management firm has licensed and/or approved captive insurance
companies under management:
10. Captive management services provided:
11. Captive management service to be sub-contracted to third parties:
12. Does the Applicant currently carry any of the following insurance coverages:
a.
Directors & Officers Liability:
Yes ___ No ___
b.
Errors & Omissions:
Yes ___ No ___
c.
Fidelity & Crime:
Yes ___ No ___
Please attach a copy of the declarations page of each insurance policy for the above
coverage’s.
13. Has the Applicant ever been denied approval as a captive insurance company management
firm in any jurisdiction?
Yes ___ No ___ If “yes”, please explain.
14. After inquiry of all directors, principals, officers and managers listed in question # 7, have
any of them ever been subject to a regulatory reprimand or disciplinary action, refused
admission or approval or lost any license as a result of professional activities?
Yes ___ No ___ if “yes”, please explain.
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15. After inquiry of all director, principal / partner, officer, manager or professional employee
at the date of the application, have any claims or suits ever been made against the Applicant
or any of the directors, principals, officers, partners or employees arising out of professional
or other services?
Yes ___ No ___ If “yes”, please explain.
16. Does any director, principal / partner, officer, manager or professional employee have any
ownership interest in any captive insurance company under management?
Yes ___ No ___ If “yes”, please explain.
17. Will any director, principal / partner, officer, manager or professional employee serve as a
board member of any captive insurance company it currently manages or will manage?
Yes ___ No ___ If “yes”, please explain.
18. Will any director, principal / partner, officer, manager or professional employee perform any
service other than captive insurance company management services for a captive insurance
company under management or for a shareholder of a captive insurer?
Yes ___ No ___ If “yes”, please explain.
19. The Connecticut Insurance Department only approved business entities to act as captive
insurance company managers in the State of Connecticut. The firm shall appoint a
responsible person to serve as a liaison between the Department and the entities managed by
the firm. Applicants should update this information as necessary.
a. Name:
b. Telephone:
c. FAX Number:
d. Email Address:
e. Business Address if different from Applicant's:
Note: The application must be signed by the President, CEO or Managing Partner of the
Applicant captive insurance company management entity.
Unless otherwise indicated, once approved, the contact information of the Applicant may
be published on the Connecticut Insurance Department Website.
Page 3 of 4
I hereby swear and affirm under penalty of law that the information provided herein is, to the best
of my knowledge, complete and truthful in all respects. I further understand that the submission
of false or inaccurate information shall be grounds for denial or rescinding of recognition of the
Applicant to act as a manager of captive insurance companies in the State of Connecticut.
I hereby certify that 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.
_________________________________
__________________________________
Name
Title
_________________________________
__________________________________
Signature
Date
Subscribed and sworn to before me this ___________ day of _______________________ 20___
Signature of Notary Public ________________________________________
Notary Public authorized by law of the State of _____________________________ to administer
oaths.
My commission expires on: ___________________________________
NOTARY SEAL
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