"Producer-Controlled Insurer Information Report Form" - New Jersey

Producer-Controlled Insurer Information Report Form is a legal document that was released by the New Jersey Department of Banking and Insurance - a government authority operating within New Jersey.

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PRODUCER-CONTROLLED INSURER INFORMATION REPORT FORM
(NOTE: Please complete only SECTION I or SECTION II)
Calendar Year Ending: December 31, 2019
Instructions: All licensed property and casualty and title insurers domiciled in New Jersey or domiciled in another State that is not a NAIC
"accredited state" having in effect a law substantially similar to N.J.S.A. 17:22D-1 et seq. are required to complete annually either SECTION I or
st
SECTION II of this form. Completed forms are due annually on or before April 1
of each year.
SECTION I
not
(To be completed by Insurers that is
Producer-Controlled)
I certify that the, _______________________________________________________________________________ NAIC#: ____________
(Name of Insurer)
_____________________________________________________________________________________________ State of Domicile: ___________
(Address of Insurer)
is not issuing any property and casualty insurance coverages that are or may be reportable pursuant to the provisions of N.J.S.A. 17:22D-1 et. seq. and
N.J.A.C. 11:2-37.1 et.. seq.
Authorized signature: ___________________________________________
Title: ___________________________________
Print Name: ___________________________________________________
Date: __________________________________
SECTION II
that is
(To be completed by Insurers
Producer-Controlled)
(A separate Report Form should be completed and filed for each controlling producer.)
Name of Reporting Insurer: ____________________________________________________________________
NAIC#: ________________
Address: __________________________________________________________________________________ State of Domicile: __________
Name of Controlling Producer: _________________________________________________
Address: ______________________________________________________________________________________________________________
1. Insurer's admitted assets as of September 30 of calendar year pursuant to N.J.S.A. 17:22D-3a:
$_________________
2. Gross premiums written of calendar year:
$_________________
3. Percentage that gross premiums written represent of admitted assets:
_________________%
4. Net premiums written of calendar year:
$_________________
5. Amount of commissions paid to controlling producer of calendar year:
$_________________
6. Percentage that commissions paid represent of net premiums written:
________________%
7. Comparable amounts and percentage paid to non-controlling producers for placement of the same kinds of insurance:
a)
Net premiums written:
$_________________
b)
Commission paid:
$__________________
c)
Percentage:
___________________%
NOTE: PRODUCER CONTROLLED INSURERS MUST ATTACH THE INFORMATION REQUIRED PER N.J.S.A. 17:22D-3e.
An opinion of an independent casualty actuary 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, on business placed by the controlling
producer.
Is the required Actuarial Opinion(s) attached? (Y or N) ____
We have notified our controlling producer(s) of the requirements of N.J.S.A. 17:22D-1 et. seq. and N.J.A.C. 11:2-37.1 et. seq. (Y or N) _____
To the best of my knowledge I certify that the above information is accurate and complete.
Authorized signature: __________________________________________________ Title: __________________________
Print Name: _________________________________________________________ Date: _________________________
PRODUCER-CONTROLLED INSURER INFORMATION REPORT FORM
(NOTE: Please complete only SECTION I or SECTION II)
Calendar Year Ending: December 31, 2019
Instructions: All licensed property and casualty and title insurers domiciled in New Jersey or domiciled in another State that is not a NAIC
"accredited state" having in effect a law substantially similar to N.J.S.A. 17:22D-1 et seq. are required to complete annually either SECTION I or
st
SECTION II of this form. Completed forms are due annually on or before April 1
of each year.
SECTION I
not
(To be completed by Insurers that is
Producer-Controlled)
I certify that the, _______________________________________________________________________________ NAIC#: ____________
(Name of Insurer)
_____________________________________________________________________________________________ State of Domicile: ___________
(Address of Insurer)
is not issuing any property and casualty insurance coverages that are or may be reportable pursuant to the provisions of N.J.S.A. 17:22D-1 et. seq. and
N.J.A.C. 11:2-37.1 et.. seq.
Authorized signature: ___________________________________________
Title: ___________________________________
Print Name: ___________________________________________________
Date: __________________________________
SECTION II
that is
(To be completed by Insurers
Producer-Controlled)
(A separate Report Form should be completed and filed for each controlling producer.)
Name of Reporting Insurer: ____________________________________________________________________
NAIC#: ________________
Address: __________________________________________________________________________________ State of Domicile: __________
Name of Controlling Producer: _________________________________________________
Address: ______________________________________________________________________________________________________________
1. Insurer's admitted assets as of September 30 of calendar year pursuant to N.J.S.A. 17:22D-3a:
$_________________
2. Gross premiums written of calendar year:
$_________________
3. Percentage that gross premiums written represent of admitted assets:
_________________%
4. Net premiums written of calendar year:
$_________________
5. Amount of commissions paid to controlling producer of calendar year:
$_________________
6. Percentage that commissions paid represent of net premiums written:
________________%
7. Comparable amounts and percentage paid to non-controlling producers for placement of the same kinds of insurance:
a)
Net premiums written:
$_________________
b)
Commission paid:
$__________________
c)
Percentage:
___________________%
NOTE: PRODUCER CONTROLLED INSURERS MUST ATTACH THE INFORMATION REQUIRED PER N.J.S.A. 17:22D-3e.
An opinion of an independent casualty actuary 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, on business placed by the controlling
producer.
Is the required Actuarial Opinion(s) attached? (Y or N) ____
We have notified our controlling producer(s) of the requirements of N.J.S.A. 17:22D-1 et. seq. and N.J.A.C. 11:2-37.1 et. seq. (Y or N) _____
To the best of my knowledge I certify that the above information is accurate and complete.
Authorized signature: __________________________________________________ Title: __________________________
Print Name: _________________________________________________________ Date: _________________________