Alabama Department of Insurance

Certified Public Accountant

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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  
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Zip  


DOB:  


Last 4 Digits of SSN:  


Email:  

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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:  

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Present Chief Occupation

Position or Title:  


Employer:


No. of Years?  


Address:  


City  


State  
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Zip  


Phone:

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Has applicant ever been arrested or indicted for and/or convicted of any crime or offense other than a traffic violation?  
YesNo
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?  
YesNo

Have you ever had a license or privilege refused or revoked by an Insurance Department?
YesNo
If yes, give details,


Are you currently licensed as a CPA?  
YesNo

License 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

Will you assign only individuals that have a minimum of two years insurance auditing experience?  
YesNo

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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.  


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