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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 3/9/2023)  
  • We will accept e-notarized documents from out of state if that state allows e-notarization.  As noted above Vermont notaries are not permitted. 
  • If circumstances dictate that you are unable to obtain notarization, please request a waiver by letter to dfr.captivemail@vermont.gov.
  • 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:

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

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 - 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.

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