Applications and Forms

Please note our web site is currently under construction with new content being added daily. 


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.

Forms & Templates

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

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.


Contact Information

Department of Financial Regulation
Commissioner Michael Pieciak
89 Main Street, Montpelier, VT 05620 - 3101

Public Information
For public records, media inquiries, and press releases visit our Public Information web page

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Employee Information