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.

The application form must be filled out in its entirety and when submitted should include all material requested together with an application fee of $200.00. 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.

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.

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.

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 Blank

Pure and Industrial Insured captives will file an annual statement on a Vermont Captive Insurance Company blank established by the Commissioner. Association captives and Risk Retention Groups will file an annual statement on the NAIC blank 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

Get Application Forms:

Important: How to use fillable forms

Two ways to use: The documents below are "fillable" PDF's which 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 experience any difficulties using the on-screen feature you can always just print out a blank copy and fill it in.

Filling in the document: When filling forms out directly on your screen, in order to move from space to space you can hit the Tab key, and you can also use the cursor or space bar to move around the form as you would with any regular document. To check a blank "checkbox", simply click on it with your cursor.

How to submit: 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.

• Application for Admission
• Application for Authorization (for Actuary) to Certify Loss Reserves
• Application for Authorization to Act as CPA for Captive Insurance Business
• Biographical Affidavit
• Irrevocable 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. Thank you.)