Applications and Forms

CAPTIVE INSURANCE

Applications and Forms

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. Applications may be submitted electronically to DFR.CaptiveMail@vermont.gov.  Please see Steps to Form a Captive for further considerations before completing and filing an application.

All forms may be submitted electronically in combined single PDF unsecure format and Zip files are NOT accepted. Please see specific form and applications general instructions for further instructions and submission address.

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
• Actuary Application - to become approved for Vermont Captives
• CPA Application - to become approved for Vermont Captives
• NAIC Foreign Risk Retention Group Application - to register as a foreign risk retention group
• NAIC Risk Purchasing Group Application - to register as a risk purchasing group

*To become an approved Vermont Captive Manager, the firm must maintain a physical presence in Vermont (a person or office with a Vermont address) who is qualified to perform the duties of captive management, and the application form is available upon request from dfr.captivemail@vermont.gov.

Forms and Templates

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

All forms may be submitted electronically in combined single PDF unsecure format and Zip files are NOT accepted. Please see specific form and applications general instructions for further instructions and submission address.

• Submittal Forms for Captives Filing on the Vermont Captive Annual Report Blank (VCAR).  Note:  Not required for NAIC Statement filers.
  • General Guidance & Instructions - Submittal Forms
    • VCAR and copy of Vermont Premium Tax Return - Submittal Form
    • Annual Audited Financial Statements - Submittal Form
    • Annual Certification of Loss Reserves and Loss Expense Reserves - Submittal Form
• 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 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.
• 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.

Vermont Captive Annual Report (VCAR) Form Templates to be used by non-NAIC filers.  [Note:  There are no changes to the 2023 VCAR templates.  Version 2023 VCARs can be rolled forward for 2024 and the below unchanged Version 2023 templates should be used for 12/31/2024 and 2025 fiscal year-end filings, until superseded.]

• Guidance for all VCAR Forms - Important please read.
• 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.