ࡱ> hjefg Ybjbj ҿeeV5vvDDD$hhhP\ht ":###*~L0$p3$ l=D54**55##.P;;;5RR#D#;5;;=""G>#ӟ:6>ٔf0>,(7(G>G>(D>V5"&5;>5R555595555555(555555555v : NEVADA DIVISION OF INSURANCE STATE SPECIFIC REQUIREMENTS FOREIGN RISK RETENTION GROUP CERTIFICATE OF REGISTRATION NRS 695E Date:  FORMTEXT       Name of Applicant:  FORMTEXT       NV ID:  FORMTEXT       FEIN:  FORMTEXT       Email Address:  FORMTEXT       The following checklist pertains to a Foreign RISK RETENTION GROUP who wishes to operate in Nevada. The Nevada Division of Insurance ( Division ) requires the following items in order to process your application. Failure to provide any of the items listed below will delay the review of your application. Please note, until all of the items listed below have been received and reviewed by the Division, you may not operate, solicit or otherwise transact insurance in Nevada. Upon completion of our review, you will receive written notice, along with a Certificate of Registration, allowing you to transact business in Nevada. 1. A letter or notice of anticipated operations in Nevada 2. Completion of NAIC Risk Retention Reporting Form - Appendix C and D  HYPERLINK "http://www.naic.org/documents/library_MDL-705_Forms.pdf" http://www.naic.org/documents/library_MDL-705_Forms.pdf 3. A copy of the Plan of Operations or Feasibility Study as submitted to the domestic state and any revisions. It must include: a) Policy and forms that will be used by the applicant b) Coverages available c) Deductibles d) Coverage limits e) Rates and Rating Classifications for each line of insurance offered f) A summary of expected results g) Historical and expected loss experience of the proposed members and the national experience of similar program" h) Proforma financial statements and projections i) Appropriate opinions by a qualified independent casualty actuary including a determination of minimum premium or participation levels required to commence operations and to prevent a hazardous financial condition j) Identification of management, underwriting procedures, policies for investment and methods for managerial oversight 4. Name used in the chartering state, Bermuda or the Cayman Islands. (Must include the words - Risk Retention Group) 5. Name of the state of domicile and date of charter 6. The principal place of business and business address and telephone number 7. A description of the RRG's members and their similar interests for its qualification as an RRG 8. A designation, on Nevada Form ID-21A of the Commissioner and its agent for Service of Process 9. A copy of the Articles of Incorporation, certified by the Secretary of State or Articles of Association, certified by the secretary of the company. Purpose clause for foreign companies - must state in the NAIC application that one of the purposes of the retention group is to purchase liability insurance on a group basis. 10. A statement identifying each state and domicile where the applicant is chartered or licensed as a liability insurer 11. A copy of the group's financial statement submitted to its state of domicile, which must be certified by an Independent CPA and contain a statement of opinion on its reserves for loss and expenses for loss adjustments made by a member of American Academy of Actuaries or another qualified specialist in reserves for loss 12. A copy of each examination of the RRG certified by the Commissioner or other public officers conducting the examination which includes the company's response 13. A letter from the domiciliary state advising the Division that the Retention Group is properly register 14. Application fees (see NRS 680C.110 Fees) a) Initial Registration and app review $250 Annual Renewal $250 b) Service of Process $5 c) Fund for Insurance Admin & Enforcement $250 Annual Renewal $250 d) Annual Statement Filing Fee $25 Annual Renewal $25 e) NAIC Assessment Fee $23 Annual Renewal $23 NRS 695E.220  Annual notice of intent to continue doing business in Nevada.  On or before March 1st of each year, a risk retention group shall submit to the Commissioner a written notice of its intention to continue doing business in Nevada and submit renewal fees. Invoices will be mailed in January. Refer any questions to  HYPERLINK "mailto:klamb@doi.nv.gov" klamb@doi.nv.gov (775) 687-0753 Submit the above information via UCAA electronic means (preferred), CD or flash drive to: Nevada Division of Insurance Kathy Lamb C&F 1818 E. College Parkway, Suite 103 Carson City, NV 89706 Send payment to the Nevada Division of Insurance via ACH or Check. ACH - MUST submit  HYPERLINK "http://doi.nv.gov/uploadedFiles/doinvgov/_public-documents/Insurers/FundsNotificationFormB.pdf" ACH Deposit Form at time of payment Check - Submit remittance advice with your check if paying an invoice; otherwise note Application Fees on the check Appendix C NAIC RISK RETENTION REPORTING FORM Company Name:  FORMTEXT       NAIC Co. Code:  FORMTEXT       Domicile:  FORMTEXT       FEIN:  FORMTEXT       Type:  FORMTEXT       (* See Below) Incorporation Date:  FORMTEXT       Commenced Business:  FORMTEXT       Statutory Home Office:  FORMTEXT       Administrative Contact Person:  FORMTEXT       Address:  FORMTEXT       Phone Number:  FORMTEXT       Officers: President:  FORMTEXT       Secretary:  FORMTEXT       Treasurer:  FORMTEXT       Management Firm:  FORMTEXT       *Company Type: 1 = Mutual 2 = Reciprocal 4 = Stock 8 = Captive A. Minimum Capital & Surplus Required to Commence Business: Capital $  FORMTEXT       Surplus $  FORMTEXT       B. Capital & Surplus as of  FORMTEXT       (date licensed) Capital $  FORMTEXT       Surplus $  FORMTEXT       Surplus to Policyholders: $  FORMTEXT       Initial Capitalization:  FORMTEXT       Cash & Other Invested Assets: $ FORMTEXT       Letter(s) of Credit  FORMTEXT       Other (Describe:  FORMTEXT      ) $ FORMTEXT       Total Initial Capitalization Surplus Notes: Amount $ FORMTEXT       Lender(s)  FORMTEXT       C. Authorized Lines of Business: (Describe Coverages, List Statutory Reference and Attach Certificate of Authority)  FORMTEXT        FORMTEXT       D. Deposit or Investment Held For the Protection of ALL Policyholders: Description:  FORMTEXT       Market Value:  FORMTEXT       E. Is Company Required to File the NAIC Annual Statement Blank?:  FORMCHECKBOX  Yes  FORMCHECKBOX No F. States in Which the Group Intends to Operate:  FORMTEXT      ,  FORMTEXT      ,  FORMTEXT      ,  FORMTEXT      ,  FORMTEXT      ,  FORMTEXT      ,  FORMTEXT      ,  FORMTEXT      ,  FORMTEXT      ,  FORMTEXT      ,  FORMTEXT      ,  FORMTEXT      ,  FORMTEXT      ,  FORMTEXT      ,  FORMTEXT      ,  FORMTEXT      ,  FORMTEXT      ,  FORMTEXT      ,  FORMTEXT      ,  FORMTEXT      ,  FORMTEXT      ,  FORMTEXT      ,  FORMTEXT      ,  FORMTEXT      ,  FORMTEXT      ,  FORMTEXT      ,  FORMTEXT      ,  FORMTEXT       G. Describe the Business of the Member:  FORMTEXT       Appendix D Part A STATE OF NEVADA DIVISION OF INSURANCE RISK RETENTION GROUP - NOTICE AND REGISTRATION 1. Name of the Risk Retention Group as it appears on its Certificate of Authority:  FORMTEXT       2. List any other name(s) by which the Risk Retention Group is known or may be doing business in this State or any other state:  FORMTEXT       3. The Risk Retention Group is a corporation or other limited liability association whose primary activity consists of assuming and spreading all, or any portion, of the liability exposure of its members. 4. The Risk Retention group is organized for the primary purpose of conducting the activity described under Item #3 above. 5. The Risk Retention Group is chartered and licensed as a liability insurance company under the laws of the State of  FORMTEXT      , and is authorized to engage in the following lines and/or classifications of insurance under the laws of its chartering State:  FORMTEXT       6. The Risk Retention Group does not exclude any person from membership in the Group solely to provide for members of the Group a competitive advantage over such a person. 7. Ownership of the Risk Retention Group consists of one or the other of the following (check one): a)  FORMCHECKBOX  the owners of the Group are the only persons who comprise the membership of the Group and who are provided insurance by the Group. b)  FORMCHECKBOX  the sole owner of the Group is:  FORMTEXT       (Name and Address of Organization) an organization which has as its members only persons who comprise the membership of the Group and which has as its owners only persons who comprise the membership of the Group and who are provided insurance by the Group. 8. The Risk Retention Group members are engaged in businesses or activities similar or related with respect to the liability to which such members are exposed by virtue of related, similar or common business, trade, product, services, premises or operations. Give a general description of businesses or activities engaged in by the Groups members:  FORMTEXT       9. The activities of the Risk Retention Group do not include the provision of insurance other than: (a) liability insurance for assuming and spreading all or any portion of the similar or related liability exposure of its Group members; and (b) reinsurance with respect to the similar or related liability exposure of another Risk Retention Group (or a member of such other Risk Retention Group) engaged in business or activities which qualify such other Risk Retention Group (or member) under Item #8 above for membership in this Group. 10. (a) List the name, social security number (SS#) and address of each officer and director of the Risk Retention Group: (Attach additional pages, if necessary.) Position With Name SS# Group Address (b) Identify and give the telephone number of the officer or director of the Risk Retention Group who can be contacted for any information regarding the management of the insurance activities of the Group: Name:  FORMTEXT       Telephone Number:  FORMTEXT       11. List the name, address, telephone number and Federal Employer Identification Number (FEIN) of the company responsible for managing the insurance operations of the Risk Retention Group and the contact person at the company: (If none, answer none.) Name FEIN Address Telephone # Contact Person:  FORMTEXT       Telephone #  FORMTEXT       12. List the name(s), SS#(s) and address(es) of the licensed insurance agent(s) or broker(s) responsible for marketing the Risk Retention Groups insurance policies and the state(s) in which they are licensed: (If none, answer none. Attach additional pages, if necessary.) Name SS# Address State(s) 13. The Risk Retention Group will comply with the unfair claim settlement practices laws of this State. 14. The Risk Retention Group will pay, on a non-discriminatory basis, applicable premium and other taxes which are levied on such Group under the laws of this State. 15. The Risk Retention Group has designated the Insurance Commissioner of this State to be its agent solely for the purpose of receiving service of legal documents or process by executing Part B of this form, attached hereto. 16. The Risk Retention Group will submit to examination by the Insurance Commissioner of this State to determine the Groups financial condition, if: (a) the Insurance Commissioner of the Groups chartering State has not begun or has refused to initiate an examination of the Group; and (b) any such examination by the Insurance Commissioner is coordinated to avoid unjustified duplication and unjustified repetition 17. The Risk Retention Group will comply with a lawful order issued in a delinquency proceeding commenced by the Insurance Commissioner of this State upon a finding of financial impairment, or in a voluntary dissolution proceeding. 18. The Risk Retention Group will comply with the laws of this State concerning deceptive, false or fraudulent acts or practices, including any injunctions regarding such conduct obtained from a court of competent jurisdiction. 19. The Risk Retention Group will comply with an injunction issued by a court of competent jurisdiction upon petition by the Insurance Commissioner of this State alleging that the Group is in hazardous financial condition or is financially impaired. 20. The Risk Retention Group will provide the following notice, in at least 10-point type, in any insurance policy issued by the Group: NOTICE This policy is issued by your risk retention group. Your risk retention group may not be subject to all of the insurance laws and regulations of your State. State insurance insolvency guaranty funds are not available for your risk retention group. 21. The Risk Retention Group has submitted to the Insurance Commissioner as part of this filing and before it has offered any insurance in this State, a copy of the plan of operation or feasibility study which it has filed with the Insurance Commissioner of its chartering State. This plan or study includes the name of the State in which the Group is chartered, as well as the Groups principal place of business, and such plan or study further includes the coverages, deductibles, coverage limits, rates, and rating classification systems for each line of insurance the Group intends to offer. The Group will promptly submit to the Insurance Commissioner of this State any revisions of such plan or study to reflect any changes to the plan if the Group intends to offer any additional lines of liability insurance, including any change in the designation of the State in which it is chartered. 22. The Risk Retention Group will submit a copy of its annual financial statement submitted to its chartering state, to the Insurance Commissioner [Director, Superintendent] of this State, by March 1 of each year. The annual financial statement will be certified by an independent public accountant and include a statement of opinion on loss and loss adjustment expense reserves made by a member of the American Academy of Actuaries or a qualified loss reserve specialist. The certification and statement of opinion on loss and loss adjustment expense reserves will be required to be submitted to its chartering state. 23. The Risk Retention Group will not solicit or sell insurance to any person in this State who is not eligible for membership in the Group. 24. The Risk Retention Group will not solicit or sell insurance in this State, or otherwise operate in this State, if the Group is in hazardous financial condition or is financially impaired. 25. The Risk Retention Group will not issue any insurance policy in this State which provides coverage prohibited generally by statute of this State or declared unlawful by the highest court of this State whose law applies to such policy. 26. The Risk Retention Group has submitted a registration fee of $  FORMTEXT      , if applicable, payable to the Insurance Commissioner of this State. 27. The Risk Retention Group will comply with all other applicable state laws. 28. The Risk Retention Group will notify the Insurance Commissioner as to any subsequent changes in any of the items included in this form. The undersigned hereby swear and affirm that the foregoing statements and information regarding their principal, the  FORMTEXT       (Name of Risk Retention Group) are true and correct.  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CJOJQJ^JaJ h 0h CJOJQJ^JaJ#h 0h >*CJOJQJ^JaJ h 0h`CJOJQJ^JaJ0MMM N)N+N,NYNZNtNvNzN{NNNNNOOO>O?OaObOfOgOOOO&P'P0P1P;PWWWWWWWWWWEXFXeXfXqXrXXXXXXXXX?Y@YIYJYNYOYhYiYlYmYYYYY)Z͚ h 0h\i CJOJQJ^JaJ h 0hCJOJQJ^JaJ h 0h&`CJOJQJ^JaJ h 0h7CJOJQJ^JaJ h 0hl'CJOJQJ^JaJ h 0h CJOJQJ^JaJ<)Z*Z+Z/Z0ZZZZZZZZ[[[!["[B[b[c[m[n[\ \ \<\>\L\N\\\\\ͼͼͼͫޖ~cͼͼR h 0hCJOJQJ^JaJ4jh 0h\i CJOJQJU^JaJmHnHu/j&h 0h\i CJOJQJU^JaJ)jh 0h\i CJOJQJU^JaJ h 0h7CJOJQJ^JaJ h 0hCJOJQJ^JaJ h 0h CJOJQJ^JaJ h 0h\i CJOJQJ^JaJ h 0h&`CJOJQJ^JaJ [[\\<]>]Z^\^__`N`P`x```a]F]H]]]]]]^Z^\^&_(_F_H_\_^_`_j_l_______޼޼ޫޖ~cK/j'h 0h\i CJOJQJU^JaJ4jh 0h\i CJOJQJU^JaJmHnHu/j&h 0h\i CJOJQJU^JaJ)jh 0h\i CJOJQJU^JaJ h 0h+CJOJQJ^JaJ h 0hCJOJQJ^JaJ h 0h\i CJOJQJ^JaJ h 0h CJOJQJ^JaJ h 0h&`CJOJQJ^JaJ__``L`N`P`R`f`h`j`t`v```` a0a2a8a:aNaParavaxaaaaaabппЮttttcaU h 0h|1CJOJQJ^JaJ h 0hiKCJOJQJ^JaJ/jw'h 0h\i CJOJQJU^JaJ h 0h&`CJOJQJ^JaJ h 0h CJOJQJ^JaJ h 0h\i CJOJQJ^JaJ)jh 0h\i CJOJQJU^JaJ4jh 0h\i CJOJQJU^JaJmHnHu!______________, Notary Public. My Commission Expires: ________________ Part B APPOINTMENT OF ATTORNEY TO ACCEPT SERVICE AND DESIGNATION The  FORMTEXT       ( the Group ), a risk retention group which is chartered and licensed as a liability insurance company under the laws of the State of Nevada, having notified the Insurance Commissioner of the State of Nevada of its intention to do business in this State as a risk retention group pursuant to the federal Liability Risk Retention Act of 1986, hereby appoints the Insurance Commissioner of the State of Nevada, any successor in office, and any authorized deputy its true and lawful attorney, in and for the State of Nevada, upon whom all legal documents or process in any proceeding against it may be served. Such service of process shall be of the same legal force and validity as if served personally upon the Group. The Group designates:  FORMTEXT       (Name)  FORMTEXT       (Address)  FORMTEXT       (City, Town or Village)  FORMTEXT       (State and ZIP Code) as its officer, agent or other person to whom shall be forwarded all legal documents or process served upon the Insurance Commissioner of the State of Nevada, any successors in office, or any authorized deputy, for the Group. This designation shall continue in full force and effect until superseded by a new written designation filed with the Insurance Commissioner. RISK RETENTION GROUP FORM This appointment and designation is made pursuant to a resolution by the Groups governing body authorizing it, and a certified copy of the resolution is attached hereto. This appointment shall be binding upon any person or corporation which as successor acquires the Groups assets or assumes its liabilities, by merger or consolidation or otherwise. This appointment may be withdrawn only upon a written notice of termination and, in any event, shall not be terminated by the Group or its successor so long as any contracts or liabilities or duties arising out of contracts entered into by the Group while it was doing business in this State are in effect. IN WITNESS OF THIS APPOINTMENT AND DESIGNATION, the Group, in accordance with the resolution of its Board of Directors duly passed on  FORMTEXT      , 20 FORMTEXT      , has affixed its corporate seal, and caused the same to be subscribed and attested in its name by its President and Secretary, at the City of  FORMTEXT      in the State of  FORMTEXT       on  FORMTEXT      , 20 FORMTEXT      .  FORMTEXT       (Name of Risk Retention Group) By: __________________________ President __________________________ Secretary State of ____________________) ) ss: County of __________________) Sworn before me this _____ day of __________________________, 20___. _________________________, Notary Public. My Commission Expires: ____________  NEVADA DIVISION OF INSURANCE APPOINTMENT DESIGNATION FOR SERVICE OF PROCESS RISK RETENTION GROUPS NRS 695E Date:  FORMTEXT       Name of Applicant:  FORMTEXT       Applicant Home Office Address:  FORMTEXT       NV ID:  FORMTEXT       NAIC:  FORMTEXT       DESIGNATED INDIVIDUAL WHO WILL ACCEPT SERVICE OF PROCESS FORWARDED BY THE COMMISSIONER OF INSURANCE Individual Name:  FORMTEXT       Address:  FORMTEXT       Dated this  FORMTEXT       day of  FORMTEXT      , 201 FORMTEXT       OFFICER CERTIFICATION AND ATTESTATION  FORMTEXT       Name of Company Officer  FORMCHECKBOX  I attest that this is my true electronic signature  FORMCHECKBOX  I acknowledge that I am authorized to execute this document on behalf of the Applicant.  FORMCHECKBOX  I hereby certify under penalty of perjury under the laws of the applicable jurisdictions that all of the forgoing is true and correct. The entity named above agrees to submit an amended Appointment for Service of Process form upon a change in any of the information provided herein.  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