The following is the uniform registration form adopted in June 1991, by the NAIC.

 

Part A

STATE OF ARKANSAS

DEPARTMENT OF INSURANCE

RISK RETENTION GROUP - NOTICE AND REGISTRATION

(All information should be typed)

 

1. Name of the Risk Retention Group as it appears on its Certificate of Authority:

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:

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 ______________________________, and is authorized to engage in the following lines and/or classifications of insurance under the laws of its chartering State:

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.) _____ 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.) _____ the sole owner of the Group is: ___________________________________________________ _____________________________________________________________________________

(Name and Address of Organization)

 

RISK RETENTION GROUP FORM -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 Groupís members.

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 or membership in this group.

10. (a) List the name, social security number (SS#) and

(b) Address of each officer and director of the Risk Retention Group: (attach additional pages, if necessary)

Name SS# Position w/RRG Address

(c) 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: _______________________________________

Telephone Number: _____________________

 

 

RISK RETENTION GROUP FORM

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: _______________________________

Telephone # ___________________________

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 Groupís insurance policies and the state(s) in which they are licensed: (If non, 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 [Director, Superintendent] 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 thereto.

16. The Risk Retention Group will submit to examination by the Insurance Commissioner [Director, Superintendent] of this State to determine the Groupís financial condition, if: (a) the Insurance Commissioner [Director, Superintendent] of the Groupís chartering State has not begun or has refused to initiate an examination of the Group; and

(b) any such examination by the Insurance Commissioner [Director, Superintendent] is

 

RISK RETENTION GROUP FORM

17. The Risk Retention Group will comply with a lawful order issued in a delinquency proceeding commenced by the Insurance Commissioner [Director, Superintendent] 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 [Director, Superintendent] 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 you risk retention group.

21. The Risk Retention Group has submitted to the Insurance Commissioner [Director, Superintendent] 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 is, has filed with the Insurance Commissioner [Director, Superintendent] of its chartering State. This plan or study includes the name of the State in which the Group is chartered, as well

as the Groupís principal place of business, and such plan or study further includes the coverageís, 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 [Director, Superintendent] 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 1st 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 submitted to the Insurance Commissioner [Director, Superintendent] of this State by the date it is 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.

 

RISK RETENTION GROUP FORM

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 $__750.00,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 [Director, Superintendent] 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 _____________________________________________ are true and correct.

 

Name of Risk Retention Group

President of the Risk Retention Group

Secretary of the Risk Retention Group

State of ____________________________) )ss:

County of __________________________)

Sworn before me this __________ day of __________________________,20____________.

____________________________________________

Notary Public

_____________________________________________________

My Commission Expires

 

RISK RETENTION GROUP FORM

Part B

APPOINTMENT OF ATTORNEY TO ACCEPT SERVICE AND DESIGNATION

The _____________________________________________________________ (ďthe GroupĒ), a Risk Retention Group organized under the laws of the State of__________________________________________, having notified the Insurance Commissioner of the State of Arkansas 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 [Director, Superintendent] of the State of Arkansas, any successor in office, and any authorized deputy its true and lawful attorney, in for the State of Arkansas, 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:

Name

Address

City, Town or Village

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 Arkansas, 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 Groupís 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 Groupís 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

________________, 20____, 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 _________________ in the State of ____________________ on

________________, 20____.

_____________________________________________

Name of Risk Retention Group

President of the Risk Retention Group

Secretary of the Risk Retention Group

State of ____________________________)

)ss:

County of __________________________)

Sworn before me this __________ day of __________________________, 20____________.

____________________________________________

Notary Public

_____________________________________________________

My Commission Expires