R590-238-21. Authorized Forms

  (1) The following forms are to be used for any applicant applying for a certificate of authority for a new captive insurance company and may be obtained from the department's captive administrator at [phone]:

  (a) "Application to Form A Captive Insurance Company;"

  (b) "Biographical Affidavit For Captive Insurance Company;"

  (c) "Utah Insurance Department Captive Insurance Company Reinsurance Exhibit;"

  (e) "Utah Approved Irrevocable Letter of Credit;"

  (f) "Statement if Economic Benefit to the State of Utah;" and

  (g) "Appointment Of The Insurance Commissioner For The State Of Utah As Attorney To Accept Service of Process."

  (2) The following forms are to be used when applying to become an Approved captive insurance company provider and are available on the department's captive website:

  (a) "Application for Placement on Approved Captive Insurer Management Firm List;"

  (b) "Application To Certify Loss And Expense For Captive Insurance Companies Captive Actuary Application;" and

  (c) "Application For Authorization As An Independent Certified Public Accountant for Captive Insurance Companies."

  (3) All captive insurance companies, except those noted in R590-238-4(2), are to use the "Captive Insurance Company Annual Statement Form."

  (4) A company shall file a "Statement of Economic Benefit to the State of Utah" form with its initial application and for each of the 12 months ending December 31, of each applicable year.

  (5) The forms indicated in Sections (2), (3), and (4) are available on the department's captive website, https://insurance.utah.gov/captive.