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Home > Insurance Division > Captive Insurance > Admission Application Packet
NJ Captive Admission Packet (For Forming a Captive Insurance Company in New Jersey)
 
Forms
Note: Most of the documents below are "fillable" PDFs which can be opened with Adobe Acrobat Reader and filled out directly on the screen. Please print the completed forms and sign where indicated. See Forming a Captive in New Jersey before submitting any application.
Office of Captive Insurance
New Jersey Department of Banking and Insurance
20 W. State St.
PO Box 325
Trenton, NJ 08625-0325
1. Captive Admission Application
2. Irrevocable Letter of Credit (if applicable)
3. Business Plan
4. Biographical Affidavits
5. Designee for Receipt of Service of Process
6. Designee to Receive Department Documents
 
In addition, the applicant should review this Captive Documents Checklist to complete or supplement the Admission Application Packet.
  • Bylaws

  • Articles of Incorporation

  • Pro forma Financial Statements (including Parent Company Financial Statements)

  • Actuarial Feasibility Study

  • Statement of Benefit to New Jersey

  • State the source and type of funding used for capitalization including Irrevocable Letter of Credit, if applicable

  • Financial Support
      a. Certified copy of organization's documents
      b. Statement under oath of captive financial condition from captive president and secretary
      c. Statement of captive parent company net worth 
      d. Description of the coverage limits and rates, together with any additional information as the Commissioner may require
      e. Amount and liquidity of assets relative to the risks to be assumed
      f. Experience, expertise, and character of officers and management staff
      g. Summary statement regarding overall soundness of Business Plan
      h. Summary statement regarding adequacy of loss prevention program(s)





  • Petition to the Commissioner for Certificate of General Good

  • Consent of Incorporators

  • Expertise, experience, and responsibilities of Service Providers:
      a. Captive Manager
      b. Audit CPA
      c. Reserving Actuary
      d. Attorney
      e. Financial Institution
      f. Risk Management
      g. TPA (Third Party Administrator)  
 
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New Jersey Department of Banking and Insurance