Captive Service Providers

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:  






Last 4 Digits of SSN:  


Education and Degree

High School:  


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:  


No. of Years?  






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).