"Captive Insurance Company - Application for Admission" - Connecticut

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

Form Details:

  • Released on January 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 "Captive Insurance Company - Application for Admission" - Connecticut

1416 times
Rate (4.5 / 5) 99 votes
STATE OF CONNECTICUT
INSURANCE DEPARTMENT
CAPTIVE INSURANCE COMPANY - APPLICATION FOR ADMISSION
Instructions:
Please answer all questions as completely as possible. A failure to address all questions completely
will cause a delay in the processing of your application.
Applicants are required to submit an original and one (1) complete copy of the application and
attachments.
All applications must be signed and notarized prior to their submission.
______________________________________________________________________________
A.
GENERAL INFORMATION:
1.
Name of Proposed Captive:
2.
Parent, Association, Industrial Insured, Risk Retention Group, Sponsor or Special Purpose Entity
seeking to form the captive:
3.
Contact Information of forming entity for purposes of this Application:
Name:
a.
Title:
b.
Address:
c.
Phone Number:
d.
E-mail address:
e.
4.
Type of Proposed Captive:
Pure
_____
a.
Association
_____
b.
Industrial Insured
_____
c.
Risk Retention
_____
d.
Other
_____
e.
5.
Organization Form of Proposed Captive
Stock
_____
a.
Mutual
_____
b.
Reciprocal
_____
c.
Limited Liability Corp.
_____
d.
Not for profit
_____
e.
(Revised 1/1/2014)
Page 1 of 7
STATE OF CONNECTICUT
INSURANCE DEPARTMENT
CAPTIVE INSURANCE COMPANY - APPLICATION FOR ADMISSION
Instructions:
Please answer all questions as completely as possible. A failure to address all questions completely
will cause a delay in the processing of your application.
Applicants are required to submit an original and one (1) complete copy of the application and
attachments.
All applications must be signed and notarized prior to their submission.
______________________________________________________________________________
A.
GENERAL INFORMATION:
1.
Name of Proposed Captive:
2.
Parent, Association, Industrial Insured, Risk Retention Group, Sponsor or Special Purpose Entity
seeking to form the captive:
3.
Contact Information of forming entity for purposes of this Application:
Name:
a.
Title:
b.
Address:
c.
Phone Number:
d.
E-mail address:
e.
4.
Type of Proposed Captive:
Pure
_____
a.
Association
_____
b.
Industrial Insured
_____
c.
Risk Retention
_____
d.
Other
_____
e.
5.
Organization Form of Proposed Captive
Stock
_____
a.
Mutual
_____
b.
Reciprocal
_____
c.
Limited Liability Corp.
_____
d.
Not for profit
_____
e.
(Revised 1/1/2014)
Page 1 of 7
6.
Address information of Proposed Captive:
Statutory Address
Mailing Address
Administrative Address
Street:
City:
State/Zip Code:
B.
CONTACT AND ORGANIZATIONAL INFORMATION
1.
Location of Books and Records of Proposed Captive:
2.
Resident Registered Agent of Proposed Captive:
a. Name:
b. Address:
c. Phone Number:
d. E-mail address:
3.
Directors of Proposed Captive:
(Include Biographical Affidavits consistent with NAIC requirements)
a. Name:
b. Address:
c. Phone Number:
d. E-mail Address:
e. Position with Proposed Captive:
a. Name:
b. Address:
c. Phone Number:
d. E-mail Address:
e. Position with Proposed Captive:
a. Name:
b. Address:
c. Phone Number:
d. E-mail Address:
e. Position with Proposed Captive:
(Attach additional sheets if needed.)
4.
Officers of Proposed Captive:
(Include Biographical Affidavits)
a. Name:
b. Address:
c. Phone Number:
d. E-mail Address:
e. Position with Proposed Captive:
a. Name:
b. Address:
c. Phone Number:
d. E-mail Address:
e. Position with Proposed Captive:
CAPTIVE APPLICATION FOR ADMISSION
(Revised 1/1/2014)
Page 2 of 7
a. Name:
b. Address:
c. Phone Number:
d. E-mail Address:
e. Position with Proposed Captive :
(Attach additional sheets if needed.)
5.
If Applicant is an Industrial Insured Captive, please answer the following:
a. Name and address of each full time employee acting as an Insurance Manager or Buyer:
b. Aggregate annual premium:
c. Number of full time employees:
C.
SERVICE PROVIDERS
1.
Captive Management Firm:
a. Firm Name:
b. Contact Name:
c. Address:
d. Phone Number:
e. E-mail Address:
2.
Legal Counsel:
a. Firm Name:
b. Contact Name:
c. Address:
d. Phone Number:
e. E-mail Address:
3.
Claims Handling Firm:
a. Firm Name:
b. Contact Name:
c. Address:
d. Phone Number:
e. E-mail Address:
4.
CPA Firm:
a. Firm Name:
b. Contact Name:
c. Address:
d. Phone Number:
e. E-mail Address:
5.
Actuarial Firm:
a. Firm Name
b. Contact Name:
c. Address:
d. Phone Number:
e. E-mail Address:
CAPTIVE APPLICATION FOR ADMISSION
(Revised 1/1/2014)
Page 3 of 7
6.
Reinsurance Broker:
a. Firm Name:
b. Contact Name:
c. Address:
d. Phone Number:
e. E-mail Address:
7.
Investment Advisor and Manager
a. Firm Name:
b. Contact Name:
c. Address:
d. Phone Number:
e. E-mail Address:
D.
FINANCIAL AND REQUIRED DOCUMENTATION TO BE SUBMITTED:
1.
Cover Letter addressed to the Insurance Commissioner, which includes, but is not limited to, an
overview of the parent, background information, coverages to be provided by the proposed captive and
requested licensing date. For association captives, provide history, purpose, size, and detail on the
parent association.
2.
Organizational Documentation:
a. Articles of Incorporation
b. Organization chart of parent company showing captive reporting lines
c. Bylaws/Operating Agreement
d. Consents of Incorporators
e. Consents of Directors and Officers
3.
Business Plan:
Provide a written business plan that includes all of the following items. If an item is not applicable or
available, please provide a detailed explanation as to why. Your business plan should contain a
comprehensive proposed program description and address the core risk and operational management
elements. The plan should provide a 5 year prospective focus, and be submitted in an organized
manner, separated by sections, as outlined below.
a. Proposed Captive Program Discussion:
1) Strategic Risk Management and Alignment with Owner(s)
2) Rationale for Alternative Risk Structure
a) Compare the owner/member risk and insurance needs with the available commercial
market solutions
b) Discuss the benefits of a captive program for the captive owner/member
3) Detailed explanation of the captive insurance program:
a) Lines of coverage(s) and methods (direct, assumed, etc.)
b) Limits and Deductibles
4) Expected Premium (Gross and Net)
b. Risk Acceptance and Funding:
1) Indentified and evaluated risk
2) Rating methodology and premium development
3) Established risk acceptance parameters, appetite and tolerances
4) Underwriting processes and controls
5) Underwriting policies and standards
CAPTIVE APPLICATION FOR ADMISSION
(Revised 1/1/2014)
Page 4 of 7
6) Maximum retained risk (per loss and annual aggregate; integration of multiple lines of
business)
c. Claim Management:
1) Claim Reporting
2) Reserve Methodology
3) Claim Event Management / Adjudication
4) Data Management
d. Reinsurance Management:
1) Original or draft copies of policies and reinsurance agreements
2) Assumed and ceded
3) Program description, including assumed cessions, and recessions
4) Proposed reinsurance management processes and responsibilities
e. Risk Improvement, Loss Prevention, and Safety:
1)
Planned programs, including identified risk areas and interventions
2)
Organization and program delivery
3)
Linkage with Risk Acceptance and Claim Management
f. Preliminary Investment Management:
1) Investment Policy
2) Planned Investment Strategy and Asset Allocation
a) Liquidity
b) Time Horizon
c) Unique Preferences
3) Investment Objectives, Tolerance and Return Assumptions
4) Retained Earnings / Dividend Plan
g. Governance and Control: Proposed Governance Structure and Processes
h. Core Data, Reports and Exhibits:
1) Loss Experience – 5 Years – Retrospective
2) Actuarial Feasibility Study
a) Finalized Assessment of Captive Risk Exposures
b) Model of Alternative Limits and Retentions
c) Estimates of Projected Expected Losses and Expenses at Selected Retention
d) Expected Losses vs. Adverse Loss Projections
e) Statistical Loss Confidence Intervals
f) Compare Risk Variability to Captive Risk Appetite & Tolerances
g) Risk Margins
h) Captive Premium Funding Levels
i) Financial Projections – Pro Forma Statements. These Financial Statements need to
demonstrate the impact of operating/underwriting strategies, reinsurance and risk/actuarial
assumptions of the proposed captive formation or redomestication. The statements must be
prepared using generally accepted accounting principles (GAAP) and must include an
Income Statement, Balance Sheet, Cash Flow Statement, and Supporting Exhibits
i.
New Captive Formation: 5 Years Prospective
ii. Redomestication; 3 Years - Audited Financials; 2 Years Prospective
3) Additional data may be required depending upon the risk, captive formation or potential risk
and operational volatility
Redomestication is typically accomplished via merger, simultaneous run-off or assumption/loss portfolio
transfer. The varying nature of these transactions typically requires submission of additional information and
data beyond what is outlined above. Additional information will be required if the proposed captive insurance
company is a sponsored captive or a special purpose financial captive and may be required of any proposed
CAPTIVE APPLICATION FOR ADMISSION
(Revised 1/1/2014)
Page 5 of 7