CAPTIVE INSURANCE
Applications, Forms and Fees
For admission as a Vermont captive insurance company, upon holding a licensure meeting with the division you must submit an application, along with supporting forms and documentation. Take note of the additional requirements and application fees listed below the application and forms.
Application and Forms
The application for admission form must be filled out in its entirety and when submitted should include all material requested together with an actuarial application review fees. No incomplete package of material will be accepted.
If letters of credit are used to meet capital and surplus requirements a Form E-702 Irrevocable Letter of Credit must be adhered to by the qualified* institution issuing the letter of credit and should be issued on bank letterhead. Copies should be made and enclosed as required by the application. Each affidavit must be filled out in its entirety and no substitute for this form will be accepted.
The application turnaround time is approximately 30 days from receipt.
Please review the tips below before starting the application process.
Tip 1 - The documents below are fillable PDF's which you should be able to open in any basic Adobe Acrobat Reader. You may (1) print them out as blank forms or (2) you can fill them out directly on your screen if you have full Adobe. Adobe Reader does not allow you to save. Exception: VCAR forms are Excel-based.
Tip 2 - Follow form guidance and instructions for submission.
Tip 3 - Letter of Credit - While this document is provided as a "sample" format, please note that if you use a different format, you must adhere to the exact wording in paragraphs 1-7. All Letters of Credit should be issued by a qualified bank* on the bank's letterhead. *A qualifying bank is a member of the Federal Reserve Bank or included on the list of NAIC approved banks.
- Annual BOD Certification of Independence for RRGs
- Application for Admission
- Application for Admission (Affiliated Reinsurance Company "ARC")
- Application for Re-Domestication or Merger
- Application for a Cell (Business Plan Change for Protected Cells)
- Biographical Affidavit (non-Vermont residents)
- 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 from DFR Captive Insurance as required. Note: The Uniform Certificate of Authority Application (UCAA) Biographical Affidavit NAIC (Form 11) is an accepted biographical affidavit form.
- Vermont Resident Director Biographical Affidavit
- Actuary Application
- CPA Application
- Certification of Review of Audit Work Papers
- Letter of Credit
- Submittal Forms Guidance
- 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) and 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 dfr.captivefinancialfilings@vermont.gov. Note: Page 5 should not be uploaded to MyVTax when the premium tax filing is made and payment remitted.
Fees
| Initial Department Licensure | $500 |
| Initial Department Licensure (SPFI) | $5,000 |
| Actuarial Application Review | $5,000 |
| Actuarial Application Review (SPFI) | $10,000 |
Additional Requirements
Financial Regulation (Select an Accountant)
Financial Regulation C-81-2 requires that an independent certified public accountant, approved by the commissioner, audit the captive annually. It is incumbent upon the applicant to select an accountant who meets the requirements of Regulation 81-2. See CPA approved list.
Certification Of Reserves (Select an Actuary)
Financial Regulation C-81-2 requires that loss reserves and loss expense reserves be certified by a Fellow of the Casualty Actuarial Society, a member in good standing of the American Academy of Actuaries or an individual who has demonstrated his competence in loss reserve evaluation and has been approved by the commissioner. It is incumbent upon the applicant to select a member or individual who meets the requirements of this regulation. See Actuary approved list.
Review Firm
All applications will be reviewed by one of the review firms appointed by the commissioner. The firms' duties are of an advisory nature only and final approval or disapproval of an application will be made by the commissioner only.
Captive Annual Statement
Pure, Association, Sponsored and Industrial Insured captives will file an annual statement #VCAR on a Vermont captive insurance company form established by the commissioner. Risk Retention Groups and Special Purpose Financial Insurance Companies will file an annual statement on the NAIC form currently in use by the insurance industry.
Location Of Captive Records
All books, records, and other information necessary for a statutory examination should be located in Vermont.