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Department of Insurance, Securities and Banking

Captive Insurance Company Application


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. Effective March 16, 2020 and until further notice, applications should be submitted electronically and hard-copy applications are not required. The electronic application should be signed and should include a detailed table of contents and should be in a single PDF document with bookmarks. Also, submit the proforma financial template in the excel format. The application and proformas should be e-mailed to [email protected] with a copy to [email protected]

The application shall be accompanied by a $500 non-refundable application review fee and a $300 certificate of authority fee. If the application is denied, the certificate of authority fee will be returned. If paying by check, a copy of the check should be included in the PDF application and the check should be submitted to the:  

DC Treasurer Insurance Bureau  
PO Box 712180  
Philadelphia, PA 19171-2180 

Payment can also be accepted via ACH or wire transfer. Please contact Hawi Chibessa at [email protected] for ACH and wire instructions.