"Risk Retention Group Form - Part a - Notice and Registration" - Oklahoma

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

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Download "Risk Retention Group Form - Part a - Notice and Registration" - Oklahoma

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This uniform registration form adopted in June 1991, by the NAIC, has been amended for use specifically
in Risk Retention Group Notice of Registration to Oklahoma.
Part A
STATE OF OKLAHOMA
INSURANCE DEPARTMENT
RISK RETENTION GROUP - NOTICE AND REGISTRATION
(All information should be typed.)
1. Name of the Risk Retention Group as it appears on its Certificate of Authority:
__________________________________________________________________________________
Statutory Address, City, State, Zip_______________________________________________________
Mailing Address, City, State, Zip________________________________________________________
NAIC# ___________ Group #__________ FEIN#__________________ State of Domicile_______
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.
This uniform registration form adopted in June 1991, by the NAIC, has been amended for use specifically
in Risk Retention Group Notice of Registration to Oklahoma.
Part A
STATE OF OKLAHOMA
INSURANCE DEPARTMENT
RISK RETENTION GROUP - NOTICE AND REGISTRATION
(All information should be typed.)
1. Name of the Risk Retention Group as it appears on its Certificate of Authority:
__________________________________________________________________________________
Statutory Address, City, State, Zip_______________________________________________________
Mailing Address, City, State, Zip________________________________________________________
NAIC# ___________ Group #__________ FEIN#__________________ State of Domicile_______
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.
RISK RETENTION GROUP FORM
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 or
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)
Name
SS#
Position w/RRG
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: ___________________
RISK RETENTION GROUP FORM
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 # ___________________________
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 non, 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 Oklahoma.
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 Oklahoma.
15. The Risk Retention Group has designated the Insurance Commissioner of Oklahoma 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 of Oklahoma
to determine the Group’s financial condition, if:
(a) the Insurance Commissioner [Director, Superintendent] of the Group’s chartering State has not
begun or has refused to initiate an examination of the Group; and
(b) any such examination by the Insurance Commissioner of Oklahoma is coordinated to avoid
unjustified duplication and unjustified repletion.
RISK RETENTION GROUP FORM
17. The Risk Retention Group will comply with a lawful order issued in a delinquency proceeding
commenced by the Insurance Commissioner of Oklahoma upon a finding of financial impairment,
or in a voluntary dissolution proceeding.
18. The Risk Retention Group will comply with the laws of Oklahoma 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 of Oklahoma 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 regulations of your State. State insurance Insolvency
guaranty funds are not available for you risk retention group.
21. The Risk Retention Group has submitted to the Insurance Commissioner of Oklahoma 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 is, 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
of Oklahoma 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
st
chartering State, to the Insurance Commissioner of Oklahoma 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 expense reserves will be submitted to the Insurance Commissioner of
Oklahoma 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 Oklahoma who is not
eligible for membership in the Group.
24. The Risk Retention Group will not solicit or sell insurance in Oklahoma, or otherwise operate in
Oklahoma, if the Group is in hazardous financial condition or is financially impaired.
RISK RETENTION GROUP FORM
25. The Risk Retention Group will not issue any insurance policy in Oklahoma, which provides coverage
prohibited generally by statute of Oklahoma or declared unlawful by the highest court of Oklahoma
whose law applies to such policy.
26. The Risk Retention Group is exempt from paying a registration fee to the Insurance Commissioner
of Oklahoma.
27. The Risk Retention Group will comply with all other applicable Oklahoma laws.
28. The Risk Retention Group will notify the Insurance Commissioner of Oklahoma 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
___________________________________________
Secretary of the
State of ____________________________)
ss:
County of __________________________)
Sworn before me this ________ day of __________________________, 20_____.
Notary Public ____________________________________________, Notary #____________________
My Commission Expires ________________________