Alabama Department of Insurance

Captive Service Providers

Captive Manager

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Captive Management Firm  


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  

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Captive manager's authorized representative

First Name  


MI  
MI A B C D E F G H I J K L M N O P Q R S T U V W X Y Z

Last Name  


Telephone  


Fax  


Email  


Organization form of applicant manager  
CorporationPartnershipLimited Liability CompanyOther Business Entity

Incorporation Date  


Incorporation Location  


During the past 5 years has the applicant operated under any different name, or has the applicant purchased, consolidated or merged with any other business, or has the applicant been purchased?  
YesNo

If yes, please explain


Captive Management Services Address
Same as Firm 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  


Address where captive records will be maintained  
Same as Firm 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  

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Names and Titles of all Staff

Principles/Partners  


Officers/Professional Staff  


Clerical and all others  


No. of captives under managerment  


Names of all domiciles where licensed or approved as a captive manager  


State captive services provided directly by the applicant  


State captive services applicant intends to subcontract to 3rd parties  


Does the applicant currently carry any of the following types of insurance?

Directors and Officers Liability	YesNo
Errors and Omissions	YesNo
Fidelity/Crime	YesNo

As of the date of this application, have any of the professional employees of the applicant ever been the subject to any of the following as a result of professional activities?

Regulatory Reprimand	YesNo
Regulatory Disciplinary Action	YesNo
Admission Refusal	YesNo
Admission Approval	YesNo
License Revocation	YesNo

Has the applicant ever been denied approval as a captive manager in any jurisdiction?  
YesNo
If yes, please explain


As of the date of this application, have any claims or suits ever been made against any of the directors, officers, principles, partners or professional employees of the applicant arising out of professional services?  
YesNo
If yes, please explain


Provide a listing of any directors, officers, principals, partners or professional employees holding an ownership interest in any captive insurance company under management. (List should state the ownership interest held.)  


Provide a listing of any directors, officers, principals, partners or professional employees that currently serve, or will serve, as a board member of any captive insurance company the applicant manages or will manage.  


State whether any director, officer, principal, partner or professional employee performs or intends to perform any services other than captive management services to a captive insurance company under management or to a shareholder of a captive insurer.  

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Biographical Affidavit  

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By electronically signing below, I hereby swear or affirm under penalty of law that the information provided herein is, to the best of my knowledge, complete and truthful in all respects. I further understand that the submission of false or inaccurate information shall be grounds for denial of approval to act as a manager of captive insurance companies in the state of Alabama.

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


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