Certified Public Accountant
To the Commissioner of Insurance, State of Alabama, Montgomery, Alabama, I hereby apply for authorization as an independent certified public accountant for the transaction of audits for Captive Insurance Companies.
All Information Is Required
First Name:
Middle Name:
Last Name:
Address:
City
State
Zip
DOB:
Last 4 Digits of SSN:
Email:
Education and Degree
High School:
College:
Graduate or Professional:
List all insurance and/or captive auditing experience for past 15 years including specific dates:
List the Alabama captive account(s) you will be auditing:
Present Chief Occupation
Position or Title:
Employer:
No. of Years?
Address:
City
State
Zip
Phone:
Has applicant ever been arrested or indicted for and/or convicted of any crime or offense other than a traffic violation?
If yes, list full particulars and disposition thereof
I control directly or indirectly, or own legally or beneficially the outstanding stock of the following insurers:
Do you currently hold or have you held any type of insurance license?
Have you ever had a license or privilege refused or revoked by an Insurance Department?
If yes, give details,
Are you currently licensed as a CPA?
License State:
Will you assign only individuals that have a minimum of two years insurance auditing experience?
By electronically signing below, I hereby certify that 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).