Fillable Captive Insurance Division Arizona Department of Insurance 100 (Arizona)

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Captive Insurance Division Arizona Department of Insurance 100 (Arizona)

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CID_Cell Supp (07 2019) Page 1 of 4
Captive Insurance Division
Arizona Department of Insurance
100 North 15
th
Avenue, Suite 261, Phoenix, Arizona 85007-2630
Phone: (602) 364-4490 | Web: https://insurance.az.gov
PROTECTED CELL CAPTIVE INSURER (PCCI)
LICENSE APPLICATION SUPPLEMENT FOR
INDIVIDUAL PROTECTED CELL (PC)
NO
TES:
1. Complete all sections clearly and completely. Limit broad references to other/separate application materials,
particularly if this application for a new cell is submitted after the original PCCI application for licensure.
2. If an item is not applicable, clearly indicate by marking “N/A”.
3. Submit a separate supplement with applicable exhibits or attachments for each cell to the address above.
4. First year license fee = $1,000 - Per cell
1. Name of Protected Cell Captive Insurer: ____________________________________________________
2. Name or other identifier of the Protected Cell: _______________________________________________
3. Who is the parent or beneficial owner / participant of the PC? If more than one, list all significant owners,
% ownership, and provide an organization chart of all related parties as an attachment.
_____________________________________________________________________________________
_____________________________________________________________________________________
4. Provide recent financial statements, preferably audited, of the PC parent or beneficial owner.
5. What is the PC participant’s business / industry? _____________________________________________
6. Is the PC (a) incorporated or (b) unincorporated? Click (a) or (b). If incorporated, provide corporate
formation documentation.
7. Have any of the parties connected with this application ever applied successfully or unsuccessfully for
authority to transact insurance business in any other jurisdiction? If so, provide details. Attach
supporting documentation or a separate sheet if more space is needed.
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
8. Proposed start-up date and/or initial coverage date of the PC? ______________
9. What is the business or risk management purpose(s) of establishing this PC?
_____________________________________________________________________________________
_____________________________________________________________________________________
10. If the sponsor, PCCI, or PC participant will make an initial capital contribution or other infusion of cash to
the cell above the initial premium, how much will be contributed? _____________________________
11. If the PC expects to maintain capital and surplus in the PC (may be required by the participation
agreement or the Department), how much will be maintained? ________________________________
12. Provide a copy of the participation agreement and any related agreements governing or affecting the PC.
Aside from the participation agreement, this may include administrative service or management
agreements, reinsurance treaties, etc. Provide a list of those agreements as an attachment.
Reset
CID_Cell Supp (07 2019) Page 2 of 4
13. Respond to all of the following questions or statements related to A.R.S. 20-1098.01(H), and .05:
a. The PCCI will separately account for each PC, including the above-referenced, to reflect the financial
condition and results of operations, net income or loss, dividends and other financial activities of
each cell? Check box to confirm:
b. How will PC loss and expense experience be accounted for and reported to the Director?
___________________________________________________________________________________
___________________________________________________________________________________
c. The financial records of the PCCI and each PC will be available for inspection or examination by the
Director? Check box to confirm:
d. The PCCI will allocate expenses fairly and equitably to each PC? Check box to confirm:
Describe the general methodology for that allocation and how it may change as PCs are added or
subtracted from the PCCI program.
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
e. With respect to this PC, the insurance business written by the PCCI is at least one of the following:
(Check all that apply)
Assumed from an insurance company licensed under the laws of this or any state
Reinsured by a reinsurer authorized or accredited by this state
Secured by a trust fund or an irrevocable letter of credit with an evergreen clause
14. Provide the following information related to the PC’s insurance program and operations:
a. What party or parties will be insured via this PC and indicate the affiliation to the PC?
_________________________________________________________________________________
_________________________________________________________________________________
b. The PC’s business will be direct written, assumed, or both. (Check one)
c. List the lines of business or coverages in the cell and provide expected 1
st
year gross and net
written premium for each:
Line of business / coverage
Gross WP $
CID_Cell Supp (07 2019) Page 3 of 4
d. For each line of business in the cell, list the per occurrence and aggregate limits:
Line of business / coverage
Per occurrence
e. Describe any ceded or assumed reinsurance related to the program. Be specific as to lines of
business, types, attachment points, other significant terms. Also indicate how credit for
reinsurance will be secured, if applicable. Attach a separate sheet if necessary.
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
f. If different from the PCCI, list the service providers specific to the PC, and describe the services to
be provided. Also indicate any direct or indirect affiliation(s) with other parties involved in the
program at the PCCI or PC level. This list may include direct writers, ceding or reinsuring carriers,
captive managers, actuaries, attorneys, or any other provider.
Service provider role
Firm/Name
Affiliation, if any
Other details/info
g. What provisions or plans are in place if the PC encounters a lack of liquidity or solvency?
_________________________________________________________________________________
_________________________________________________________________________________
h. Describe any plans or expectations for profit sharing, dividends, or other distributions that may
involve the PC and its participant(s). If planned, how will amounts and timing be determined, by
whom, and on what grounds?
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
[CERTIFICATION on next page]
CID_Cell Supp (07 2019) Page 4 of 4
CERTIFICATION
I certify that the information given in this application is true and correct and that all estimates given are true
estimates based upon facts that have been carefully considered and assessed. I affirm that pursuant to A.R.S. §20-
1098.01 the Protected Cell Captive Insurer will notify the Arizona Director of Insurance within thirty days of any
material change in the information filed with this application.
Name: _______________________________________ Date:___________________________
Signature: ____________________________________ Title: ___________________________
Subscribed and sworn to before me this _________ day of _____________________ 20 _______
Signature of Notary Public: _____________________________________________________________
NOTARY SEAL: Notary Public authorized by law of the State of _________________________
to administer oaths.
My commission expires on __________________________________________
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Captive Insurance Division Arizona Department of Insurance 100 (Arizona)

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Completed 12 August 2020

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