General Licensing Forms and Instructions

At the bottom of this page are links to application forms for admission as a captive insurance company together with a sample letter of credit form and biographical affidavit form. Special Purpose Financial Captives may be subject to different instructions and forms. If you are forming a Special Purpose Financial Captive, please contact us directly to obtain additional information.

The application form must be filled out in its entirety and when submitted should include all material requested together with an actuarial application review fee of $4,000.00 ($7,500 for SPFCs). No incomplete package of material will be accepted.

If letters of credit are used to meet capital and surplus requirements a Form E-702 Irrevocable Letter of Credit must be adhered to by the institution issuing the letter of credit. Copies should be made and enclosed as required by the application. Each affidavit must be filled out in its entirety and no substitute for this form will be accepted.  Click here for the E-702 Irrevocable Letter of Credit form.

Financial Regulation (Select an Accountant)

Financial Regulation 81-2 requires that an independent certified public accountant, approved by the Commissioner, audit the captive annually. It is incumbent upon the applicant to select an accountant who meets the requirements of Regulation 81-2. You may ask the Department if your CPA is currently approved. Click here for the Application for Authorization to Act as CPA for Captive Insurance Companies form.

Certification Of Reserves (Select an Actuary)

Financial Regulation 81-2 requires that loss reserves and loss expense reserves be certified by a Fellow of the Casualty Actuarial Society, a member in good standing of the American Academy of Actuaries or an individual who has demonstrated his competence in loss reserve evaluation and has been approved by the Commissioner. It is incumbent upon the applicant to select a member or individual who meets the requirements of this regulation.  Click here for the Application for Authorization (for Actuary) to Certify Loss Reserves form.

Review Firm

All applications will be reviewed by one of the nine review firms appointed by the Commissioner. The firms' duties are of an advisory nature only and final approval or disapproval of an application will be made by the Commissioner only.

Captive Annual Statement

Pure, Association and Industrial Insured captives will file an annual statement on a Vermont Captive Insurance Company form established by the Commissioner. Risk Retention Groups will file an annual statement on the NAIC form currently in use by the insurance industry.

Location Of Captive Records

All books, records, and other information necessary for a statutory examination should be located in Vermont.

Application Turnaround Time

Approximately 30 Days from receipt.

Forms

Note 1:  The documents below are "fillable" PDF's which you should be able to open in any basic Adobe Acrobat Reader. You may (1) Print them out as blank forms, or (2) You can fill them out directly on your screen if you have full Adobe.  Adobe Reader does not allow you to save.

Note 2:  These forms cannot be submitted on-line. You must print out the completed forms, sign as needed, and mail them in. You can save your completed document on your hard drive for your records.

Note 3:  Letter of Credit - While this document is provided as a "sample" format, please note that if you use a different format, you must adhere to the exact wording in paragraphs 1-7.