Form FIS0233 "Foreign Risk Retention Group (Frrg) Application for Registration" - Michigan

What Is Form FIS0233?

This is a legal form that was released by the Michigan Department of Insurance and Financial Services - a government authority operating within Michigan. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on May 1, 2015;
  • The latest edition provided by the Michigan Department of Insurance and Financial Services;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form FIS0233 by clicking the link below or browse more documents and templates provided by the Michigan Department of Insurance and Financial Services.

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Download Form FIS0233 "Foreign Risk Retention Group (Frrg) Application for Registration" - Michigan

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FIS 0233 (5/15) Department of Insurance and Financial Services Page 1 of 2
The name and Tax ID number of the FRRG must be entered as
Foreign Risk Retention Group (FRRG)
indicated on each form and/or indicated in the upper right
corner of each attachment to this application.
Application for Registration
Name of Foreign Risk Retention Group (FRRG) Applicant – name must include the phrase “Risk Retention Group”
TPA Tax ID number (FEIN)
dba’s (assumed names) used in this or any other state
NAIC Code
Provide the following information regarding the FRRG Applicant:
State of Domicile
Date of Charter
Principal Business Address Line 1 (must include street address)
Lines of Insurance the FRRG is authorized to engage in by the chartering state:
Address Line 2
City
State
ZIP Code
Describe the ownership of the risk retention group by checking one box below:
Name of organization
The owners are persons who
The owners are persons
OR
comprise the membership of
who are provided insurance
Address
the risk retention group and
by the group. If you
are provided insurance by
checked this box, enter
the group.
the name and address of
the organization.
City
State
ZIP Code
The risk retention group is composed of members who are engaged in business or activities which are similar or related with respect to the liability to which such
members are exposed by virtue of a related, similar or common business, trade, product, service(s), premises or operations. Please describe the business or activities
that members of the group are engaged in:
Company responsible for management of the
Principle agent or broker responsible for marketing
or check if
or check if
None
None
insurance operations of the risk retention group
the risk retention group’s insurance policies
Company name
Name
Contact Person Name and Title
Producer License Number
State Licensed In
Street Address
Floor / Suite Number
Street Address
Floor / Suite Number
Address Line 2
Address Line 2
City
State
ZIP Code
City
State
ZIP Code
Telephone Number (including Area Code)
Telephone Number (including Area Code)
Fax Number (including Area Code)
Fax Number (including Area Code)
Email Address
Email Address
FIS 0233 (5/15) Department of Insurance and Financial Services Page 1 of 2
The name and Tax ID number of the FRRG must be entered as
Foreign Risk Retention Group (FRRG)
indicated on each form and/or indicated in the upper right
corner of each attachment to this application.
Application for Registration
Name of Foreign Risk Retention Group (FRRG) Applicant – name must include the phrase “Risk Retention Group”
TPA Tax ID number (FEIN)
dba’s (assumed names) used in this or any other state
NAIC Code
Provide the following information regarding the FRRG Applicant:
State of Domicile
Date of Charter
Principal Business Address Line 1 (must include street address)
Lines of Insurance the FRRG is authorized to engage in by the chartering state:
Address Line 2
City
State
ZIP Code
Describe the ownership of the risk retention group by checking one box below:
Name of organization
The owners are persons who
The owners are persons
OR
comprise the membership of
who are provided insurance
Address
the risk retention group and
by the group. If you
are provided insurance by
checked this box, enter
the group.
the name and address of
the organization.
City
State
ZIP Code
The risk retention group is composed of members who are engaged in business or activities which are similar or related with respect to the liability to which such
members are exposed by virtue of a related, similar or common business, trade, product, service(s), premises or operations. Please describe the business or activities
that members of the group are engaged in:
Company responsible for management of the
Principle agent or broker responsible for marketing
or check if
or check if
None
None
insurance operations of the risk retention group
the risk retention group’s insurance policies
Company name
Name
Contact Person Name and Title
Producer License Number
State Licensed In
Street Address
Floor / Suite Number
Street Address
Floor / Suite Number
Address Line 2
Address Line 2
City
State
ZIP Code
City
State
ZIP Code
Telephone Number (including Area Code)
Telephone Number (including Area Code)
Fax Number (including Area Code)
Fax Number (including Area Code)
Email Address
Email Address
FIS 0233 (5/15) Department of Insurance and Financial Services Page 2 of 2
Identify each of the following types of affiliate in relation to the FRRG applicant. Attach additional pages if necessary.
 ALL officers* of the corporation,
 ALL stockholders
 ALL members if company is organized
 ALL members of the Board of Directors of the corporation,
partners, or owner
of 10% or more
as a limited liability company
including Board of Trustees, Executive Committee, and any
other governing body
*Officers include, but are not limited to: Chief Executive Officer (CEO), Chief Operating Officer (COO), Chief Financial Officer (CFO), President, Vice President, Secretary, Treasurer.
Name
Title and/or stock %
Name
Title and/or stock %
IMPORTANT NOTE: Each person listed above must complete an FIS 0361 Affiliation Statement to submit with this application in order for the application to be
considered complete and to be reviewed for approval.
Filing Checklist: Please place the Foreign Risk Retention Group Name and Tax ID Number in the upper right corner of each attachment to this application.
Attach FIS 0361 Affiliation Statement forms, completed and signed by
Attach an exhibit of historical or expected loss experience, financial
each affiliate listed on this application
statements for 3 years, or projections for 3 years.
.
Attach a copy of group’s plan of operation, or feasibility study, and any
Attach appropriate opinions by a qualified independent casualty
revisions filed in group’s charter state.
actuary.
Attach a signed, completed FIS 0234 Foreign Risk Retention Group
Send completed application package with payment enclosed to:
Consent to Service form.
Attach a signed, completed FIS 0364 Report of Operations form.
Department of Insurance and Financial Services
Insurance Licensing Section
PO Box 30165
Attach a check or money order payable in US Dollars to “State of
Lansing, MI 48909-7665
Michigan” in the amount of $25.00.
CERTIFICATION:
I swear under penalties of perjury that the information above and attached is true, accurate, and complete.
Signer’s Name (typed or printed)
Signer’s Title (typed or printed)
Signature
Date signed
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