Statement from Commissioner Pieciak: DFR staff continue to work remotely and will do so until further notice. The department is still conducting business, however there may be some temporary delays in DFR services. 

Applications and Forms

CAPTIVE INSURANCE

TEMPORARY NOTICE DURING WORK FROM HOME RESTRICTIONS:  Notarization on applications, biographical affidavits, forms and other filings
  • Documents requiring a notarized signature will be accepted without a notary, electronic signatures are acceptable, and  notarized documents should be submitted at the first opportunity a notary is available or accessible.  If you are able to obtain a notary by any of these alternate means, no follow-up submissions are required:
  • We will accept e-notarized documents from out of state if that state allows e-notarization. 
  • The Vermont Secretary of State just adopted an emergency rule which allows for notarial acts to happen in Vermont by remote means through a secure audio-­visual communication link, i.e., webcam notarization. The notary and person making the oath are essentially connected and talking face-to-face electronically over a secure link while, for example, the oath is being administered.  There are a number of technology companies that offer end-to-end remote notarization systems. They include:

Applications

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

(NEW)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.

Audit and SAO Submital Form - New mandatory fillable PDF for all captive filers                                                                 (General Instructions for reference only)

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)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

 

Contact Information

Department of Financial Regulation
Consumer Services 
89 Main Street, Montpelier, VT 05620 - 3101

802-828-3301
833-DFR-HOTLINE (toll free)
833-337-4685 (toll free)

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

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Employee Information