Department of Insurance Dover Office has moved effective 7/15/2019. Please mail all the checks for Captive Applications and Premium Taxes to the new address: 1351 West North Street, Suite 101, Dover, DE 19904. logo
Insurance Program

List of Captive Forms

Below is a list of forms that can be found on this Captive website:

Form A-1 — Captive Application for Certificate of Authority

Form A-2 — Series Application

Form B-1 — Biographical Affidavit

Form B-2 — Declaration Affidavit of Financial Institutions as Trust Trustees

Form C-1 — Account Bank Balance Confirmation Form

Form C-2 — Sample Owner’s Request for Balance Confirmation

Form C-3 — Sample Surplus Note

Form C-4 — Sample Letter of Credit

Form D-1 — Designation for Receipt of Delaware Documents

Form D-2 — Designation for Receipt of Service of Process

Form E-1 — Actuarial Authorization Application

Form E-2 — Captive Manager Authorization Application

Form E-3 — Certified Public Accountant Authorization Application

Form F-1 — Annual Report for Pure Captives, Core LLCs and Series Captive Insurance Companies Updated as of 2/25/2019

Form F-2 — Annual Report for Other Captive Entities Updated as of 2/25/2019

Form F-3 — Quarterly Captive Report Updated as of 2/25/2019

Form G-1 — Dormant Status Request Form Updated as of 8/14/2019

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