Captive Service Providers

Captive Manager

Enter All Information

Download Affidavit

Captive Management Firm  





Captive manager's authorized representative

First Name  


Last Name  




Organization form of applicant manager  

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?  

If yes, please explain

Captive Management Services Address




Address where captive records will be maintained  




Names and Titles of all Staff


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  
Errors and Omissions  

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  
Regulatory Disciplinary Action  
Admission Refusal  
Admission Approval  
License Revocation  

Has the applicant ever been denied approval as a captive manager in any jurisdiction?  

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?  

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.  

Biographical Affidavit  

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.  

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