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Captive Insurance Company Application


This application shall be accompanied by a $500.00 non-refundable application review fee and a $300.00
certificate of authority fee.  If the application is denied, the certificate of authority fee will be returned.  

Answer each question on this application.  If a question is not applicable, respond by indicating “not applicable.”  Do not leave
a question blank.  Incomplete applications will be returned.  Submit one signed original and four copies in three-ring binders,
and include a detailed table of contents and clearly marked tabs with each copy.