"Risk Retention Group Notice and Registration Form" - Mississippi

Risk Retention Group Notice and Registration Form is a legal document that was released by the Mississippi Department of Insurance - a government authority operating within Mississippi.

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MAILING ADDRESS:
MIKE CHANEY
Commissioner of Insurance
P.O. Box 79
State Fire Marshal
Jackson, MS. 39205-0079
Phone: 601-359-3569
Fax: 601-359-2474
MARK HAIRE
Deputy Commissioner of Insurance
MISSISSIPPI INSURANCE DEPARTMENT
501 N. WEST STREET, SUITE 1001
WOOLFOLK BUILDING
JACKSON, MISSISSIPPI 39201
www.mid.ms.gov
REGISTRATION REQUIREMENTS FOR RISK RETENTION GROUPS
Please submit the following items with your initial application:
1.
A copy of the plan of operation or feasibility study that has been filed with the insurance Commissioner of its
chartering state which includes the coverages, deductibles, coverage limits, rates, and rating classification systems
for each line of insurance the group intends to offer (which shall include the name of the state in which it is
chartered and it principal place of business).
2.
A copy of any revisions to such plan or study if the group intends to offer any additional lines of liability
insurance ( which shall include any change in the designation of the State in which it is chartered).
3.
A copy of the group’s annual financial statement submitted to the State in which the group is chartered as an
insurance company, which statement shall be certified by an independent public accountant and contain a
statement of opinion on loss and loss adjustment expense reserves made by:
a) A member of the American Academy of Actuaries, or
b) A qualified loss reserve specialist.
4.
The most recent Report of Examination from the State of domicile.
5.
The Risk Retention Group – Notice and Registration Part A & Part B. (see attached)
6.
Certificate of Authority and compliance from the State of domicile. (Must be within two (2) years.)
_________________________________________________________________________________________________________
Mississippi Risk Retention Group Registration
Page 1 of 7
  
MAILING ADDRESS:
MIKE CHANEY
Commissioner of Insurance
P.O. Box 79
State Fire Marshal
Jackson, MS. 39205-0079
Phone: 601-359-3569
Fax: 601-359-2474
MARK HAIRE
Deputy Commissioner of Insurance
MISSISSIPPI INSURANCE DEPARTMENT
501 N. WEST STREET, SUITE 1001
WOOLFOLK BUILDING
JACKSON, MISSISSIPPI 39201
www.mid.ms.gov
REGISTRATION REQUIREMENTS FOR RISK RETENTION GROUPS
Please submit the following items with your initial application:
1.
A copy of the plan of operation or feasibility study that has been filed with the insurance Commissioner of its
chartering state which includes the coverages, deductibles, coverage limits, rates, and rating classification systems
for each line of insurance the group intends to offer (which shall include the name of the state in which it is
chartered and it principal place of business).
2.
A copy of any revisions to such plan or study if the group intends to offer any additional lines of liability
insurance ( which shall include any change in the designation of the State in which it is chartered).
3.
A copy of the group’s annual financial statement submitted to the State in which the group is chartered as an
insurance company, which statement shall be certified by an independent public accountant and contain a
statement of opinion on loss and loss adjustment expense reserves made by:
a) A member of the American Academy of Actuaries, or
b) A qualified loss reserve specialist.
4.
The most recent Report of Examination from the State of domicile.
5.
The Risk Retention Group – Notice and Registration Part A & Part B. (see attached)
6.
Certificate of Authority and compliance from the State of domicile. (Must be within two (2) years.)
_________________________________________________________________________________________________________
Mississippi Risk Retention Group Registration
Page 1 of 7
STATE OF MISSISSIPPI
MISSISSIPPI DEPARTMENT OF INSURANCE
RISK RETENTION GROUP - NOTICE AND REGISTRATION
(All Information Should Be Typed)
Part A
1.
Name of the Risk Retention Group as it appears on its Certificate of Authority:
_____________________________________________________________________________________________
2.
List any other name(s) by which the Risk Retention Group is known or may be doing business in this State or any other
state:
______________________________________________________________________________________________
______________________________________________________________________________________________
3.
The Risk Retention Group is a corporation or other limited liability association whose primary activity consists of
assuming and spreading all, or any portion, of the liability exposure of its members.
4.
The Risk Retention Group is organized for the primary purpose of conducting the activity described under item #3 above.
5.
The risk Retention Group is chartered and licensed as a liability insurance company under the laws of the State of
__________________________, and is authorized to engage in the following lines and/or classifications of insurance
under the laws of its chartering State:
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
6.
The Risk Retention Group does not exclude any person from membership in the Group solely to provide for members of
the Group a competitive advantage over such a person.
7.
Ownership of the Risk Retention Group consists of one or the other of the following (check one):
a) ____ the owners of the Group are the only persons who comprise the membership of the Group and who are provided
insurance by the Group.
b) ____ the sole owner of the Group is: _____________________________________________________________
_____________________________________________________________________________________________
(Name and Address of Organization)
an organization which has as its members only persons who comprise the membership of the Group and which has as its
owners only persons who comprise the membership of the group and who are provided insurance by the Group.
_________________________________________________________________________________________________________
Mississippi Risk Retention Group Registration
Page 2 of 7
8.
The Risk Retention Group members are engaged in businesses or activities similar or related with respect to the liability to
which such members are exposed by virtue of related, similar or common business, trade, product, services, premises or
operations. Give a general description of businesses or activities engaged in by the Group’s members.
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
9.
The activities of the Risk Retention Group do not include the provision of insurance other than:
a) Liability insurance for assuming and spreading all or any portion of the similar or related liability exposure of its
Group members; and
b) Reinsurance with respect to the similar or related liability exposure of another Risk Retention Group (or a member of
such other Risk Retention Group) engaged in business or activities which qualify such other Risk Retention Group (or
member) under item #8 above for membership in this group.
10.
a)
List the name, social security number (SS#) and address of each officer and director of the Risk Retention Group:
(Attach additional pages, if necessary.)
Position with
Name
SS#
Risk Retention Group
Address
________________________ _____________ ________________________ _________________________________
________________________ _____________ ________________________ _________________________________
________________________ _____________ ________________________ _________________________________
________________________ _____________ ________________________ _________________________________
b) Identify and give the telephone number of the officer or director of the Risk Retention Group who can be contacted for
any information regarding the management of the insurance activities of the Group:
Name: ______________________________
Telephone Number: _______________________________
11.
List the name, address, telephone number and Federal Employer Identification Number (FEIN) of the company responsible
for managing the insurance operations of the Risk Retention Group and the contact person at the company: (if none,
answer none)
Name
FEIN
Address
Telephone #
______________________ ________________ ____________________________ ________________________
______________________ ________________ ____________________________ ________________________
Contact Person: ______________________________
Telephone Number: _____________________________
_________________________________________________________________________________________________________
Mississippi Risk Retention Group Registration
Page 3 of 7
12.
List the name(s), SS#(s) and address (es) of the licensed insurance agent(s), or broker(s) responsible for marketing the Risk
Retention Group’s insurance policies and the state(s) in which they are licensed: (If none, answer none. Attach additional
pages, if necessary.)
Name
SS#
Address
State(s)
______________________ _________________ ____________________________ _______________________
______________________ _________________ ____________________________ _______________________
______________________ _________________ ____________________________ _______________________
13.
The Risk Retention Group will comply with the unfair claim settlement practices laws of this state.
14.
The Risk Retention Group will pay, on a non-discriminatory basis, applicable premium and other taxes, which are levied
on such Group under the laws of this State.
15.
The Risk Retention Group has designed the Insurance Commissioner [Director, Superintendent] of this State to be its agent
solely for the purpose of receiving service of legal documents or process by executing Part B of this form, attached thereto.
16.
The Risk Retention Group will submit to examination by the Insurance Commissioner [Director, Superintendent] of this
State to determine the Group’s financial condition, if:
a) the Insurance Commissioner [Director, Superintendent] of the Group’s chartering State has not or has refused to
initiate an examination of the Group; and
b) any such examination by the Insurance Commissioner [Director, superintendent] is coordinated to avoid unjustified
duplication and unjustified repetition.
17.
The Risk Retention Group will comply with a lawful order issued in a delinquency proceeding commenced by the
Insurance Commissioner [Director, Superintendent] of this State upon a finding of financial impairment, or in a
Voluntary dissolution proceeding.
18.
The Risk Retention Group will comply with the laws of this State concerning deceptive, false or fraudulent acts
.
or practices, including any injunctions regarding such conduct obtained from a court of competent jurisdiction
19.
The Risk Retention Group will comply with an injunction issued by a court of competent jurisdiction upon
Petition by the Insurance Commissioner [Director, Superintendent] of this State alleging that the Group is in
hazardous financial condition or is financially impaired.
20.
The Risk Retention Group will provide the following notice, in at least 10-point type, in any insurance policy
issued by the Group:
NOTICE
This policy is issued by your risk retention group. Your risk retention group may not be subject to all of the
insurance laws and regulation of your State. State insurance insolvency guaranty funds are not available for
your risk retention group.
_________________________________________________________________________________________________________
Mississippi Risk Retention Group Registration
Page 4 of 7
21.
The Risk Retention Group has submitted to the Insurance Commissioner [Director, Superintendent] as part of this filing and
before it has offered any insurance in this State, a copy of the plan of operation or feasibility study which it has filed with the
insurance Commissioner [Director, Superintendent] of its chartering State. This plan or study includes the name of the State
in which the Group is chartered, as well as the Group’s principal place of business, and such plan or study further includes the
coverage’s, deductibles, coverage limits, rates, and rating classification systems for each line of insurance the Group intends
to offer, The Group will promptly submit to the Insurance Commissioner [Director, Superintendent] of this State any
revisions of such plan or study to reflect any changes to the plan if the Group intends to offer any additional lines of liability
insurance, including any change in the designation of the State in which it is chartered
22.
The Risk Retention Group will submit a copy of its annual financial statement submitted to its chartering State, to the
st
Insurance Commissioner [Director, Superintendent] of this State, by March 1
of each year. The annual financial statement
will be Certified by an independent public accountant and include a statement of opinion on loss and loss adjustment expense
reserves made by a member of the American Academy of Actuaries or a qualified loss reserve specialist. The certification and
statement of opinion on loss and loss adjustment expenses reserves will be submitted to the Insurance Commissioner
[Director, Superintendent] of this State by the date it is required to be submitted to its chartering state.
23.
The Risk Retention Group will not solicit or sell insurance to any person in this State who is not eligible for membership in
the Group.
24.
The Risk Retention Group will not solicit or sell insurance in this State, or otherwise operate in this State, if the Group is in
hazardous financial condition or is financially impaired.
25.
The Risk Retention Group will not issue any insurance policy in this State, which provides coverage prohibited generally by
statute of this State or declared unlawful by the highest court of this State whose law applies to such policy.
26. The Risk Retention Group will comply with all other applicable state laws.
27. The Risk Retention Group will notify the Insurance Commissioner [Director, Superintendent] as to any subsequent changes in
any of the items included in this form.
The undersigned hereby swear and affirm that the foregoing statements and information regarding their principal, the
______________________________________________________________ (Name of Risk Retention Group) are true and correct,
___________________________________
(President of the Risk Retention Group)
___________________________________
(Secretary of the Risk Retention Group)
State of ____________________________)
) ss:
County of __________________________)
Sworn before me this _______________ day of ______________________, 20____.
___________________________________, Notary Public. My Commission Expires: _________________________
_________________________________________________________________________________________________________
Mississippi Risk Retention Group Registration
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