"Application for Recognition - Captive Insurance Company Independent Certified Public Accountant" - Connecticut

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

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Download "Application for Recognition - Captive Insurance Company Independent Certified Public Accountant" - Connecticut

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STATE OF CONNECTICUT
INSURANCE DEPARTMENT
Application for Recognition:
Captive Insurance Company Independent
Certified Public Accountant
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: _____________________________________
4.
Membership in Professional Societies or Associations:
QUALIFICATIONS: In order to be considered for recognition as an independent certified
public accountant for a captive insurance company, that is acceptable to the Insurance
Commissioner, 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.
5. Present Occupation:
Position or Title: _________________________________ Length of time: _________
Firm or Employer Name: ________________________________________
Address: _______________________________________________________________
Email Address: ___________________________Would you like to be listed on the
Connecticut Insurance Department website? ___
Phone number:________________
Time with this firm / employer: ________________
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 Independent
Certified Public Accountant
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: _____________________________________
4.
Membership in Professional Societies or Associations:
QUALIFICATIONS: In order to be considered for recognition as an independent certified
public accountant for a captive insurance company, that is acceptable to the Insurance
Commissioner, 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.
5. Present Occupation:
Position or Title: _________________________________ Length of time: _________
Firm or Employer Name: ________________________________________
Address: _______________________________________________________________
Email Address: ___________________________Would you like to be listed on the
Connecticut Insurance Department website? ___
Phone number:________________
Time with this firm / employer: ________________
www.ct.gov/cid
P.O. Box 816 Hartford, CT 06142-0816
An Equal Opportunity Employer
6.
Describe relevant Property & Casualty and/or Life & Health insurance company and
captive insurance company auditing experience:
7. Additional significant and relevant experience, positions, or titles held:
8. Describe your CPA firm in terms of its history, business size, portfolio of clients, lines of
business:
9.
In order to be recognized as an independent certified public accountant for a captive
insurance company that is acceptable to the Insurance Commissioner, the candidate must
be credentialed. Please check the applicable box(es) relating to your qualification(s).
I am currently a licensed certified public accountant (CPA) in the
State of__________________________. Include a copy of certificate.
Have you ever been subject to a regulatory
YES
NO
1.
reprimand or disciplinary action, refused admission
or approval or lost any license as a result of
professional activities? If “yes”. Please explain.
_________________________________________________________________
________________________________________________________________________
Will you assign only individuals that have a minimum
2.
3.
10.
YES
NO
of two years auditing experience to audit engagements?
Have you ever been arrested, or indicted for and /or
5.
4.
a. YES
NO
convicted of any crime or offense other than a traffic
violation? If “ YES”, submit full particulars of each
case and disposition thereof.
Page 2 of 4
11. I control directly or indirectly, or own legally or beneficially the outstanding stock of the
following insurers:
________________________________________________________________________
________________________________________________________________________
12. Insurance Licenses held, or ever held:
Type:
State:
Expiration Date:
_______________________________________________________________________
_______________________________________________________________________
13. List the current captive insurance programs that you have experience with and indicate
which Connecticut captive program(s) you intend to be auditing:
14. Please provide two (2) professional references, with appropriate contact information:
15. Attach a complete resume or CV.
Page 3 of 4
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 _________________
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