Applications & Forms

Captive Formation

Formation, Oversight, and Examination Process [pdf]
Index for Captive Application [pdf]
Captive Insurance Company License Application [pdf] (Required Adobe 9 or higher)
Protected Cell Captive Insurance Company Individual Cell Application [pdf]
Dividends and Distributions Request Form [pdf]
(NAIC) Biographical Affidavit for Risk Retention Groups only [pdf]
(TN) Biographical Affidavit for all other applications [pdf]
Irrevocable Letter of Credit [pdf]
Depository Agreement [pdf]
Securities Account Control Agreement [pdf]
(NAIC) Service of Process Form [pdf] (for Risk Retention Groups only)
Form B [pdf]
Form C [pdf]

Service Providers

Actuary Designation Form [pdf]
Captive Manager Designation Form [pdf]
Certified Public Accountant Designation Form [pdf]

Annual Statement and Premium Tax

2020 – Annual Statement Package for non RRGs  (due March 15) [pdf]
2020 – Annual Statement Package for RRGs  (due March 1st) [pdf]
2020 – Captive Filings Memo with Premium Tax Information (due March 15) [pdf] 

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