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Applications and Forms

applications, forms, listsTEMPORARY NOTICE DURING WORK FROM HOME RESTRICTIONS:Notarization on applications, biographical affidavits, forms and other filings.

  • For documents requiring a notarized signature it is our expectation that documents be notarized, whether original or remote.
  • Per the Vermont Secretary of State, Vermont notaries are allowed to notarize remotely (Effect. 9/15/2021; Further Extended and Expires 3/3/2024)  
  • We will accept e-notarized documents from out of state if that state allows e-notarization.  As noted above Vermont notaries are not permitted. 
  • There are several technology companies that offer end-to-end remote notarization systems, which may be permitted by other states where the notarization originates.  They include, but not limited to:


For admission as a Vermont captive insurance company, you must submit an application, along with supporting forms and documentation. Take note of the additional requirements and application fees. 

Special Purpose Financial Insurance Companies (SPFIs) may be subject to different instructions and forms. If you are forming a Special Purpose Financial Insurance Company, please contact us directly to obtain additional information.

Our current application forms are as below.  For all other applications or questions please contact DFR Captive Insurance.

Application for Admission - General- including general instructions

Application for Admission - Affiliated Reinsurance Company- including general instructions

Application for Admission - Redomestication or Merger- including general instructions

Business Plan Change Form for Addition of Protected Cells - including general instructions and guidance

Actuary Application - to become approved for Vermont Captives

CPA Application - to become approved for Vermont Captives

Forms & Templates

Our current required forms and templates are as below.  For questions please contact DFR Captive Insurance.


All forms may be submitted electronically in combined single PDF unsecure format and Zip files are NOT accepted. Please see specific form and applications general instructions for further instructions and submission address.

(NEW) Submittal Forms for Captives Filing on the Vermont Captive Annual Report Blank (VCAR).  Note:  Not required for NAIC Statement filers.

General Guidance & Instructions - Submittal Forms

Biographical Affidavit - including general instructions

Please note that the "Abbreviated Biographical Affidavit" is to be used to submit significant changes to Biographical Affidavit Forms already on file.  The form is available upon request to DFR Captive Insurance as required.

Biographical Affidavit - Vermont Resident Directors ONLY - including general instructions

CPA Certification of Review of Audit Work Papers- required for all audit filings

Letter of Credit- required content and 7 provisions

RRG Independence Certification- sample WORD template for annual submission


Vermont Captive Annual Report (VCAR) Form Templates to be used by non-NAIC filers beginning with 2023 year-end filings, including subsequent fiscal year-ends, until superseded.

  • 2023 Guidance for all VCAR Forms - Important please read.
  • 2023 Instructions for all VCAR Forms - For reference.
  • VCAR Form - To be used by all Vermont licensed captives that are non-NAIC filers.  Excel file name = "VCAR Form - Version 2023"
  • VCAR Supplemental Form - To be used for unincorporated protected cells, separate accounts, and filings for insurance subsidiaries, unless required to file on NAIC forms.  Excel file name = "VCAR Supplemental Form - Version 2023".
  • VCAR Incorporated Protected Cell (IPC) Form - To be used for required separate reporting by the incorporated protected cells (IPC) of Vermont licensed sponsored captives, unless required to file on NAIC forms.  Excel file name = "VCAR Incorporated Protected Cell Form - Version 2023".
  • VCAR - Premiums (Page 5 only) - To be used by all fiscal year-end captives to report premium at 12/31 corresponding to Vermont Premium Tax filing.  DFR requires a copy of the final tax return and page 5 be filed with  Note:  Page 5 should not be uploaded to MyVTax when the premium tax filing is made and payment remitted.