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Forms and Templates

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

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.


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

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 with 7 provisions

RRG Independence Certification- sample WORD template to be filed annually


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to be used by non-NAIC filers beginning with 2023 year-end filings, including subsequent fiscal year-ends, until superseded.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.