Louisiana Department of Insurance Application Form for Specialty Insurer

APPLICATION TO ACT AS A SPECIALTY INSURER IN THE STATE OF LOUISIANA

General Information (Type or Print)

APPLICANT NAME:

FEDERAL EMPLOYER IDENTIFICATION (FEIN) NUMBER:

STATUTORY ADDRESS:

CONTACT ADDRESS:

EMAIL:

ALT. CONTACT ADDRESS:

EMAIL:

SECTION 1 – FEES

Vehicle Mechanical Breakdown Insurer - License Fee $1,500.00; Recordation of Charter $25.00; Contract Form Review $25.00; Total Amount This Check $1,550.00.

Property Residual Value Insurers - License Fee $1,500.00; Recordation of Charter (Articles of Incorporation) $25.00; Contract Form Review ($100.00 per product) $25.00; Total Amount This Check $1,550.00.

ALL CHECKS MUST BE MADE PAYABLE TO THE LOUISIANA DEPARTMENT OF INSURANCE.

The review process will not begin until all fees are paid. The Department may convert your payment by check to an ACH debit transaction.

SECTION 2 - INTERROGATORIES

Except as otherwise indicated below, all of the following questions must be answered for every applicant. Attach a full explanation for any "YES" answers.

1) Has the applicant ever had an application denied by any regulatory authority? YES NO

2) Has the applicant ever been placed under any type of regulatory supervision? YES NO

3) Has the applicant ever had a Certificate of Authority or license revoked or suspended by any regulatory authority? YES NO

4) Has the applicant ever been subject to any regulatory action including cease and desist orders or similar actions? YES NO

5) Has the applicant ever changed its name? YES NO

6) Has the applicant ever redomesticated? YES NO

7) Within the last five years, has the applicant transferred or encumbered a substantial portion of its assets or business? YES NO

8) Within the last five years, has the applicant merged or consolidated with any other entity? YES NO

9) Within the last five years, has the applicant undergone a change in ownership of 10% or more? YES NO

10) Is the applicant presently negotiating or inviting negotiations or party to a counterletter which would result in transfer or encumbrance of a substantial portion of its assets or business? YES NO

11) Is the applicant presently negotiating or inviting negotiations or party to a counterletter which would result in a merger or consolidation with any other company? YES NO

12) Is the applicant presently negotiating or inviting negotiations or party to a counterletter which would result in a change of ownership of 10% or more? YES NO

13) Has the applicant undergone a change of management or control since the date of the latest financial statement filed in support of this application? YES NO

14) Does the applicant contemplate a change in management or any transaction which would normally result in a change of management within the reasonably foreseeable future? YES NO

15) Is the applicant owned, operated or controlled by any other state, province, district, territory, nation, or governmental subdivision or agency? YES NO

16) Has any person presently an officer, director or owner of 10% or more ever been convicted of or pleaded guilty or nolo contendere to a felony or misdemeanor other than minor traffic violations? YES NO

17) Is the applicant currently engaged in any controversy with any state or federal regulatory agency? YES NO

18) Is the applicant a plaintiff or defendant or subject in any legal action other than one arising from policy claims? YES NO

19) Is the applicant a defendant in any lawsuit asking for a judgment equal to or greater than 10% of the policyholder surplus? YES NO

20) Is the applicant presently licensed as an insurance agent or broker? YES NO

21) Within the last five years, has the applicant made a loan to an entity owned or controlled by one or more officers, directors, trustees, investment committee members or owners of 10% or more? YES NO

22) Within the last five years, has the applicant sold or transferred assets to such an entity? YES NO

23) Within the last five years, has the applicant purchased securities, assets or property from such an entity? YES NO

24) If any of questions 22, 23 or 24 were answered yes, did any relevant person receive money or valuable thing for negotiating or aiding in such transaction? YES NO

25) Does the applicant have any reinsurance contracts requiring reimbursement or indemnification of the reinsurer? YES NO

26) Is the applicant affiliated with any insurers authorized or approved to do business in this state? YES NO

27) Does the domiciliary regulatory authority have statutes or regulations restricting disclosure to the Louisiana Department of Insurance? YES NO

28) Is the applicant required to be licensed in its domiciliary state to supply the proposed coverage or services? YES NO

29) Is the applicant licensed in any state other than its domiciliary state to provide the proposed coverage or services? YES NO

30) Is the applicant or its parent corporation a publicly traded company? YES NO

SECTION 3 - LIST OF MANAGEMENT AND OWNERS

Provide information for all persons responsible for the conduct of affairs of the applicant. Use resident address for each individual.

SECTION 4 - EXHIBITS

Exhibit A: Articles of incorporation or organizational documents.

Exhibit B: Bylaws certified by secretary.

Exhibit C: Certificate of good standing from Louisiana Secretary of State.

Exhibit D: Certificate of compliance for foreign applicants licensed in domiciliary state only.

Exhibit E: Domiciliary certificate of authority for foreign and alien applicants.

Exhibit F: Affidavit of Non-regulation.

Exhibit G: Authorization For The Release Of Information form.

Exhibit H: Plan of operation.

Exhibit I: Corporate organizational structure description and chart.

Exhibit J: Evidence of statutory deposit.

Exhibit K: Audited financial statement.

Exhibit L: Unaudited financial statement for foreign and alien applicants only.

Exhibit M: Report of reserves.

Exhibit N: Affidavit of source of funds for domestic applicants only.

Exhibit O: Reinsurance agreements.

Exhibit P: Biographical affidavits.

Exhibit Q: Fingerprint cards.

Exhibit R: Investigative reports.

Exhibit S: Duplicate copies of applications, policy forms, service agreements, contracts, and brochures.

SECTION 5 - ADDITIONAL INFORMATION

1) U.S. Legal Counsel (if alien applicant):

2) United States Trustee (if alien entity):

3) Supervisory claims office responsible for Louisiana claims:

4) Contact person/division for consumer complaints:

5) Contact person/division for contract forms questions:

6) Financial institution(s) where funds are on deposit (domestic applicants only):

7) URL / World Wide Web address:

8) Toll free number for Louisiana consumers:

9) Does the applicant have a plan/program to promote employment and/or participation of minorities, women and/or persons with disabilities?
YES NO

If yes, explain:

10) Does the applicant have a program to prevent insurance fraud?
YES NO

If yes, provide detailed explanation:

ATTESTATION

State of

County or Parish of

Before me, the undersigned authority, personally appeared and , who, after being duly sworn, did depose and say...

Sworn to and subscribed before me this day of , 20.

AFFIDAVIT OF NON-REGULATION

State of

County of

I, as an officer of domiciled in do hereby certify...

AUTHORIZATION FOR RELEASE OF INFORMATION

The organized under the laws of authorizes the release of information to the Louisiana Department of Insurance.

CERTIFIED COPY OF RESOLUTION

Certified copy of a resolution passed by the Board of Directors or other governing body of the on the day of , A.D. 20.

This resolution authorizes release of information to the State of Louisiana.