"Producer-Controlled Annual Report Form" - Nebraska

Producer-Controlled Annual Report Form is a legal document that was released by the Nebraska Department of Insurance - a government authority operating within Nebraska.

Form Details:

  • Released on January 1, 2016;
  • The latest edition currently provided by the Nebraska Department of Insurance;
  • 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 Nebraska Department of Insurance.

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Download "Producer-Controlled Annual Report Form" - Nebraska

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STATE OF NEBRASKA
DEPARTMENT OF INSURANCE
PRODUCER-CONTROLLED ANNUAL REPORT
FOR THE YEAR ENDING DECEMBER 31,
INSTRUCTIONS: All property and casualty insurers licensed in Nebraska and domiciled in Nebraska, and
in jurisdictions other than the U.S. are required to complete this form on April 1 of each year for each producer
who “controls” such insurer, pursuant to Neb. Rev. Stat. § 44-5701 et seq., as amended, the Producer-
Controlled Property and Casualty Insurer Act. Return report to Nebraska Department of Insurance, P.
O. Box 82089, Lincoln, NE 68501-2089.
SECTION I
Controlled Insurer’s Name:
Address:
City
State
Zip Code
Form Completed
Telephone
By:
Number:
SECTION II
Name of Controlling
Producer:
Address:
City
State
Zip Code
1.
What is the aggregate amount of gross written premium on
business placed with the controlled insurer by the controlling
producer as of December 31 of the prior year?
$
2.
What is the amount of the controlled insurer’s admitted assets as
reported in the annual statement as of December 31 of the prior
year?
$
3.
What is the percentage of the gross written premium of the
controlled insurer’s admitted assets?
%
4.
What is the amount of commission the controlled insurer paid to
the controlling producer for placement of insurance as of
December 31 of the prior year?
$
5.
What is the percentage such amount represents of the net
premiums written? (See Line 4)
%
6.
What are the comparable amounts and percentages paid to non-
Commisssions Paid
controlling producers for placements of the same kinds of
insurance as of December 31 of the prior year?
$
Percentage
%
7.
Attach an opinion of an independent casualty actuary or such other independent loss reserve specialist
acceptable to the Director of the Nebraska Department of Insurance reporting loss ratios for each line of
business written and attesting to the adequacy of loss reserves established for losses incurred and
outstanding as of year end, including losses incurred but not reported and loss-adjustment expenses, on
business placed by the controlling producer.
Signature
PCAR 2016
STATE OF NEBRASKA
DEPARTMENT OF INSURANCE
PRODUCER-CONTROLLED ANNUAL REPORT
FOR THE YEAR ENDING DECEMBER 31,
INSTRUCTIONS: All property and casualty insurers licensed in Nebraska and domiciled in Nebraska, and
in jurisdictions other than the U.S. are required to complete this form on April 1 of each year for each producer
who “controls” such insurer, pursuant to Neb. Rev. Stat. § 44-5701 et seq., as amended, the Producer-
Controlled Property and Casualty Insurer Act. Return report to Nebraska Department of Insurance, P.
O. Box 82089, Lincoln, NE 68501-2089.
SECTION I
Controlled Insurer’s Name:
Address:
City
State
Zip Code
Form Completed
Telephone
By:
Number:
SECTION II
Name of Controlling
Producer:
Address:
City
State
Zip Code
1.
What is the aggregate amount of gross written premium on
business placed with the controlled insurer by the controlling
producer as of December 31 of the prior year?
$
2.
What is the amount of the controlled insurer’s admitted assets as
reported in the annual statement as of December 31 of the prior
year?
$
3.
What is the percentage of the gross written premium of the
controlled insurer’s admitted assets?
%
4.
What is the amount of commission the controlled insurer paid to
the controlling producer for placement of insurance as of
December 31 of the prior year?
$
5.
What is the percentage such amount represents of the net
premiums written? (See Line 4)
%
6.
What are the comparable amounts and percentages paid to non-
Commisssions Paid
controlling producers for placements of the same kinds of
insurance as of December 31 of the prior year?
$
Percentage
%
7.
Attach an opinion of an independent casualty actuary or such other independent loss reserve specialist
acceptable to the Director of the Nebraska Department of Insurance reporting loss ratios for each line of
business written and attesting to the adequacy of loss reserves established for losses incurred and
outstanding as of year end, including losses incurred but not reported and loss-adjustment expenses, on
business placed by the controlling producer.
Signature
PCAR 2016