(1) Provide timely reports on loss activity.

(2) To initiate a claim.

(3) To discuss useful data for improving your captive risk management program design.

Email the information in the fields below to “” at least semi-annually whether you have claims to make against your captive or not. All insured companies are required to timely report any event that could cause a claim, or a claim could be denied. Claim reports assist in improving a captive insurance program. We encourage preparing loss reports at least semi-annually (quarterly is best) even if no formal claims are being submitted for investigation. These reports should discuss all unexpected risk related events, including those covered by commercial insurance policies. They should also discuss main risk areas of concern and determine if existing insurance program sufficiently addresses the current risk environment. The following form or any similar written report should be used periodically and mail to “” if you are a client captive.

Loss Activity Claim Report

Captures data on any potential loss incident or related loss and litigation activity
  • Enter your captive name and the date of preparation of this report
  • Type in name of person preparing this report, your phone number, and your email.
  • If none applicable, write "none" in this box. Otherwise, describe in detail with date of occurrence any potential event that occurred since your last report that could cause a claim against your captive. If you are unsure if covered by one or more of your captive's policies, describe the event anyway. If you made any claims or notified your commercial insurance broker of a potential claim, describe those events in detail as well.
  • By loss event described above, estimate of range of potential loss you may incur and have to pay, and an estimate of timeline from today to resolve the exact amount and payments. List first by payments made, and then by future potential payment losses.
  • If you are submitting a formal claim against the captive for reimbursement of any loss described above that an insured company actually has paid, please describe the evidence of loss you have (documentation), and the amount of your loss you request be reimbursed. A claim representative will contact you to investigate and assess the validity of the claim and whether it is covered under a captive insurance policy.
  • Please describe risks that worry you, especially any new concerns that your existing captive design may not adequately cover.