Intake Form

Name

Company Name

Company Address

Company Gross Revenue

Net Pre-Tax Income (If Known)

Personal Contact Number (Include Extension if Necessary)

Primary Business Phone Number (If Different)

Requested Name of Captive Insurance Company

Alternative Names of Captive Insurance Company

Direct Ownership Shareholders, Name, Email Address, Percentage of Ownership

Name of LLC or Trust (If Shareholder Above is an LLC or Trust)

Name, Title, and Email Address of Company Officers

Name of Responsible Party for SS-4

Company Personal Property Values (T.I.V.)

Inventory (T.I.V)

Replacement Property Values

Key Customers

Key Suppliers

Total In-Force Coverage (All Lines)

Total Insurance Premiums (All Lines)

General Liability Gross Premium

Workman's Comp Gross Premium

Auto Gross Premium

EPL Gross Premium

Property Gross Premium

Other Gross Premium Total

Safety Program / Loss Control Data

General Liability Effective Date

General Liability Expiration Date

General Liability Carrier

General Liability Policy Deductible

General Liability Policy Limit

General Liability Location(s) by City, State, Zip Code

Insurance Current Exposure

Five-Year Currently Valued Loss Data, Plus Current Year

Five-Year Exposure Data (i.e. vehicle count, payroll, revenue), Plus Current Year

Large Losses in Excess of $50,000 (Include brief description)

Provide Copy of Operating Agreement or Trust Document (As Appropriate)

Max. file size: 50 MB.

Provide Copies of All Policies Being Considered for Captive Investment

Max. file size: 50 MB.

Two-Year Current Audited Financials

Max. file size: 50 MB.

Do you have Gross Revenue Data, Payroll Data, Premium Summaries, and Loss Run Data for the Last Five Years?

Yes

Company In Business Less Than Five Years

Intake Form

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