Arizona Department of Insurance

FINANCIAL REPORTING - DOMESTIC: Captive Insurer

NEW ADDRESS

Arizona Department of Insurance
100 North 15th Avenue, Suite 261
Phoenix, AZ  85007-2630

Starting July 1, 2020, we will be the
Department of Insurance and Financial Institutions (DIFI).

NOTICE

Arizona state agencies are experiencing telephone system problems that may impact your ability to reach us.  If you can e-mail us instead (see our CONTACT US page), please do so.  We do not have an estimate time by which the problem will be resolved.  We are very sorry for any inconvenience this is causing.

Wed, 07/23/2014 - 12:27

Captive News

3/22/2017:  The Captive Annual Filing Portal now accepts captive renewal fee payments by credit card (Visa, MasterCard or Discover) or by ACH electronic check!  Please use the portal to pay your fee.  

2/29/2016:  Captive insurers must use Arizona's new secure, encrypted Captive Insurer Annual Filing Portal ("Portal"), available at https://azinsurance.online/upload/captiveannual, to upload all documents pertaining to the annual filing. 

NOTE: Domestic risk retention groups submit most filings directly to the NAIC but will use the Portal to file the signed Jurat page for the annual and quarterly blanks, the actuarial opinion summary, and the Certificate of Disclosure (Form E-178). 

Using the Portal is free, easy, secure, and eliminates the hassle of having to send information by mail on CDs/DVDs.

Contact the Captive Insurance Division at (602) 364-4490 if you have any questions about the Portal or filing requirements.

ANNUAL FILINGS
For Captives Other Than RRGs: Captive Insurer Annual Report and Renewal Fee Transmittal

This form provides a checklist of captive insurer annual filing requirements.  Pay the annual renewal fee via the online portal or mail a check to the Department of Insurance either with this form or a printout of the "Success!" page you receive after uploading Annual Report documents to the Captive Insurer Annual Report Portal. 

NOTE: Domestic captive RRGs have a different checklist.  See Below.
For Risk Retention Groups: Captive Insurer Annual Report and Renewal Fee Transmittal

This form provides a checklist of captive RRG insurer annual filing requirements.  Pay the annual renewal fee via the online portal or mail a check to the Department of Insurance either with this form or a printout of the "Success!" page you receive after uploading Annual Report documents to the Captive Insurer Annual Report Portal.

NOTE: Domestic RRGs will use the Portal to file the annual and quarterly signed Jurat pages, the annual Form E-178, and the actuarial opinion summary, and will continue to file most other documents through the NAIC.
Captive Insurer Annual Report

Complete this form as part of the required annual filing for insurers licensed as (non-RRG) captives, unless instructed by the Department to use a different format. RRGs file using the NAIC Blank.
Captive Insurer Annual Filing Portal Instructions

Captive insurers other than domestic risk retention groups must use Arizona's new Captive Insurer Annual Filing Portal ("Portal"), available at https://azinsurance.online/upload/captiveannual, to upload all documents pertaining to the annual filing. RRGs also use the portal on a limited basis.  This document contains instructions for using the Portal.
Form E-178: Certificate of Disclosure
ADOI Fee Schedule

Fees are nonrefundable upon payment.  ARS § 20-167(A)
CREDIT PROPERTY EXPERIENCE REPORT, ANNUAL STATEMENT SUPPLEMENT
CREDIT LIFE, DISABILITY AND UNEMPLOYMENT EXPERIENCE REPORT

AD HOC FILINGS