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.