Please complete estimated answers to as many of the questions below as are applicable to your situation. We can then share with you our free preliminary assessment and cost proposal if we agree a captive appears to make sense for improving your risk management program.

All information is kept strictly confidential.

  • Client Primary Contact Person Information

  • Your Business & Investment Entities

  • To add more businesses, please use the + sign to the right.
    Legal Company NameType of Entity (Corp. LLC, S Corp, etc)Headquarter AddressShort Business DescriptionMain Website URLStates and Countries You Do Business In 
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  • To add more businesses, please use the + sign to the right.
    Company NameList Licenses & PermitsRevenues (last year, this year's estimate, and next year projected)Total AssetsReal Property AssetsInventory AssetsNumber of Employees (specify full-time, part-time and contract staff #s)Gross payroll 
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  • List and explain any customer or supplier that accounts for more than 10% of your business activity and how your business would b e impacted financially if they were lost.
  • Please explain if you have any bad debts and significant account receivable collections risks.
  • List your licenses and permits to conduct business and the local, state and federal agencies who regulate your business.
  • If yes explain how you collect, receive, process, transmit, share, maintain and use sensitive and private data. Specify types including credit cards, medical information, bank records, social security #s, employee personal data, customer information, IP of others, etc.
  • TypeLoss LimitsDeductiblesPremiumsPolicy Coverage Period 
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  • Estimate policy claims payments if you do not have actual loss histories (by type of commercial policy). ALSO, estimate the range of annual deductibles you paid the past 5 years by type of policy.
  • Provide details of any losses and legal disputes in the past and pending or threatened. Include all litigation matters whether plaintiff or defendant and legal fees incurred.
  • Explain if you have any significant key employees, trade secrets and intellectual property and losses and $ amounts you could lose if you lose such employees or competitors get access to or violate your IP and confidential property rights.
  • PLEASE describe your most serious risk concerns you want to target with a captive program. Estimate the dollar range of losses that could occur from disruptive events, such as business interruption, regulatory actions, unfair competition, reputation damage, supply chain disruption, data & IT security breaches, litigation risks, whistle blower actions, uncovered property loss events like hurricane, tornado or flood, etc. The higher your potential loss exposures, the higher the indicated initial premiums should be to properly insure these risks.
  • Please describe existing loss and safety control programs. Also describe any planned expansions of such programs.
  • Tell us which types of commercial insurance expense you would like to reduce by fully self-insuring or by increasing deductibles and annual aggregate retention levels. Specify how high of a deductible and retention you are willing to risk absorbing (by self insurance or a formal captive program). Discuss what excess coverage levels you want to remain in place.
  • What level of annual premium are you able to commit to a new captive insurance company risk coverage program?
  • Please provide a list of materials you are attaching to supplement this questionnaire. Please make sure files are in Word or PDF formats only. Maximum number of files you can attach here is 5. Rather than attaching documents, you may email them to tom@captiveexperts.com.
    Drop files here or
  • Please describe any additional information that will help expedite our assisting you and answer your questions.
  • Miscellaneous Information Needed (to form the captive and complete a license application, biographical affidavits, conflict of interest statements and/or other information may be needed from all officers, directors and 10% or greater shareholders)

  • Names and addresses of all parties who will be officers of the captive
    Officer NameOfficer Address 
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  • Names and addresses of all parties who will be directors of the captive.
    Director NameDirector Address 
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  • Owner NameOwner AddressPercentage of Ownership 
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  • Have any of the proposed owners, officers or directors been convicted of a felony that has not been expunged of record? If yes, explain dates and nature of offense.
  • Do any of the proposed owners, officers, and directors have any professional or occupation related licenses? If yes state if any have ever been denied or suspended and why.
  • Please provide 3 acceptable names for your captive
    Captive Name 1Captive Name 2Captive Name 3 
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  • Optional - please provide names, phone numbers and email addresses of your key advisers including your insurance broker, lawyer and CPA.
    Advisor NameAdvisor PhoneAdvisor Email 
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