Alabama Department of Insurance

Actuary

---

All Information Is Required

First Name  


Middle Name  


Last Name  


Address  


City  


State
Select State AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY

Zip  


DOB  


Last 4 Digits of SSN  


Email  

---

Education and Degree

High School  


College  


Graduate or Professional  


List Professional Societies or Associations Memberships  

---

Present Chief Occupation

Position or Title  


No. of Years?  


Employer  


No. of Years?  


Address  


City  


State  
Select State AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY

Zip  


Phone:


Other jobs, positions, directorates, or officerships concurrently held at present  


Employment record for the past 20 years  


Indicate property and casualty loss reserve and loss expense reserve experience  


List the Alabama captive account(s) you will be certifying  


In order to qualify to sign statements of opinion relating to loss and loss adjustment expense reserves for a captive insurance company, an applicant must qualify in one or more of the following areas

Check all that apply  
A member of the Casualty Actuarial Society and three years of property and casualty loss and loss expense reserve experience.
A member in good standing of the American Academy of Actuaries and five years of property and casualty loss and loss expense reserve evaluation experience.
A property and casualty loss reserve specialist with at least ten years of experience, three of which shall have included responsibiltiy for:

• the overall reserve level or a significant protion of the overall reserve level;
• or qualifying overall reserves or a significant portion of overall reserves;
• or the prospective evaluation of the reasonableness of the overall reserves or significant portion of the overall reserves.

---

By electronically signing below, I hereby certify that my responses to the above are true and complete, and I have read and understand all of the requirements and provisions of the Alabama Captive Insurers Act and will fully comply therewith.

Please enter a four-digit number of your choosing in the box to sign this document.  


For additional security, please check the checkbox below (and complete any puzzle prompts you may receive).

reCAPTCHA verification