Your Certificate of Authority to operate as a captive insurance company in the State of Kansas may be continued according to K.S.A. 40-4307 provided that your company complies with Kansas law upon submission of the following material prior to March 1 annually and paying the annual fee of $10,000 per K.S.A. 40-4302d.
• Please email your annual report of financial condition to kdoi.rf@ks.gov. • Please answer the questions and submit this online form. • You will be taken to a payment portal after pressing submit on this application.
Regarding the annual report:
• It must be verified by oath of two of its executive officers. • The report must be filed with generally accepted accounting principles. • The captive insurance company may make a written application to file the report 60 days after the company’s fiscal year end instead or prior to March 1 annually.
Company Name:
Relevant statutes: K.S.A. 40-4302, 40-4313, 40-4320, 40-4307, 40-4310
1. Does this captive insurance company insure any risks other than those of its parent and affiliated companies? Yes No a. If no, is the risk a controlled unaffiliated business totaling 5% or less of your total direct written premium? Yes No N/A b. If yes on 1(a), have you received prior approval for said risk? Yes No N/A 2. Is this an association captive insurance company? Yes No a. Does the association captive insurance company expose itself to loss on any one risk or hazard in an amount exceeding 10% of its paid-up capital and surplus? Yes No N/A 3. Does the captive insurance company provide personal lines of insurance, workers’ compensation, employers' liability insurance coverage, long-term care coverage, critical care coverage, surety, title insurance, or credit insurance? Yes No 4. Does the captive insurance company accept or cede reinsurance except as provided in K.S.A. 40-4311, and amendments thereto? Yes No 5.Does the captive insurance company provide accident and health, life insurance or annuities on a direct basis? Yes No 6. If the captive insurance company is authorized to transact business under article 9 or 11 of chapter 40 of the Kansas Statutes Annotated, and amendments thereto, does the company engage in the business of life insurance? Yes No N/A 7. If the captive insurance company writes life insurance, does the company transact business other than life insurance? Yes No 8. Does the board of directors, members, partners, managers, committee of managers or other governing body hold at least one meeting each year in Kansas? Yes No 9. Has the captive insurance company authorized the Kansas Insurance Department to accept service of process on its behalf in accordance with K.S.A. 40-218? Yes No 10. Is the captive insurance company a pure captive insurance company with not less than $250,000 in capital in the form of cash, or upon approval of the commissioner, an irrevocable letter of credit issued by a bank chartered by the state of Kansas or the United States comptroller of currency, domiciled in Kansas, and approved by the commissioner? Yes No N/A a. Is the captive insurance company an association captive insurance company with not less than $500,000 in capital in the form of cash, or upon approval of the commissioner, an irrevocable letter of credit issued by a bank chartered by the state of Kansas or the United States comptroller of currency, domiciled in Kansas, and approved by the commissioner? Yes No N/A b. Does the pure captive insurance company make loans or investments in its parent company or affiliates without prior written approval of the insurance commissioner? Yes No N/A c. Did the captive insurance company utilize any loans to meet minimum capital and surplus requirements? Yes No 11. Does the captive insurance company’s investment portfolio comply with K.S.A. 40-4310? Yes No 12. Does the captive insurance company belong to or benefit from any insolvency guarantee funds? Yes No 13. Has the association captive insurance company notified the association member(s) that it does not participate in any guaranty or insolvency fund in Kansas? Yes No N/A 14. Will the captive insurance company notify the Kansas Insurance Department of the sale, exchange, lease, mortgage, assignment, pledge, or other transfer of or granting of a security interest in all or substantially all the assets of a captive insurance company as required for prior approval? Yes No 15. Will the captive insurance company notify the Kansas Insurance Department of the making of a loan, investment or extension of credit by a captive insurance company, provided each such transaction is equal to or exceeds 3% of the captive insurance company's admitted assets, except as provided in K.S.A. 40-430, and amendments thereto as required for prior approval? Yes No 16. Will the captive insurance company notify the Kansas Insurance Department of the any distribution or dividend out of the capital and surplus, or otherwise for prior approval? Yes No 17. Will the captive insurance company notify the Kansas Insurance Department of the any merger or consolidation to which a captive insurance company is a party for prior approval? Yes No 18. Will the captive insurance company notify the Kansas Insurance Department of any conversion of a captive insurance company to another business form for prior approval? Yes No 19. Will the captive insurance company notify the Kansas Insurance Department of any transfer to or domestication in any jurisdiction by a captive insurance company for prior approval? Yes No 20. Will the captive insurance company notify the Kansas Insurance Department of any amendment of the organizational documents of a captive insurance company for prior approval? Yes No
