Captive Insurance Division
Arizona Department of Insurance
100 North 15
th
Avenue, Suite 102, Phoenix, Arizona 85007-2624
Phone: (602) 364-4490 | Web: https://insurance.az.gov
CAPTIVE RRG – ANNUAL REPORT AND RENEWAL FEE TRANSMITTAL
Submit certain required annual filings using the Captive Insurer Annual Report web portal at:
https://insurance.az.gov/insurers/financial-reporting-domestic-entities/captive-insurer
CID-RRG Annual Transmittal (10/2018)
INFORMATION ABOUT THE RISK RETENTION GROUP
Home Office Street Address
On what date each year does the insurer’s
fiscal year end? ►
INFORMATION ABOUT THE PREPARER
Preparer’s Mailing Address
REQUIREMENTS CHECKLIST (submit payment by mail or electronically through the portal; submit all
other documents not filed directly with the NAIC through the AZDOI filing portal unless noted otherwise below)
☐ $5,500.00 (Pay Code 87) Certificate of Authority Renewal Fee
●Make payable to Arizona Department of Insurance. ●Write the license/NAIC number in the memo section of
the payment or on the payment stub. ●Mail payment to the address at the top of this form. Payment may also
be made via e-check or credit card through the Captive Insurer Annual Report web portal.
☐ RRG Annual Statement, submitted electronically directly to the NAIC
☐ RRG Annual Statement Jurat Page, signed by two officers of the captive insurer and the
captive manager, submitted via the portal (also applicable for quarterly filings)
☐ Risk Based Capital Report, submitted electronically to the NAIC
☐ Actuarial Opinion, submitted electronically to the NAIC, unless exempt or waived ☐
☐ Actuarial Opinion Summary, submitted via the portal, unless exempt or waived ☐
☐ Management Discussion and Analysis, submitted electronically to the NAIC
☐ Form E-178: Certificate of Disclosure, submitted via the portal
☐ Annual audited financial report, submitted to the NAIC, unless exempt or waived ☐
☐ Holding Company filings if applicable (e.g. Form B, C, F, etc.), submitted via e-mail to
financialfilings@azinsurance.gov
☐ Annual disclosure regarding RRG Board independence (A.R.S. 20-2402.C.2)
IMPORTANT: Any risk retention group failing to file its annual report or pay its annual renewal fee on or before the due
date is subject to financial penalties and suspension of its Arizona Certificate of Authority pursuant to A.R.S. §20-1098.07.
