The Tennessee Captive Insurance Company License Application is the form an insurance agency files with the Tennessee Department of Commerce and Insurance to get a Certificate of Authority to run its own agency captive. An agency captive is a small insurance company that an agency or brokerage owns, and it earns a share of the premiums and underwriting profit on the business that agency places. You file this form because you cannot legally collect those reinsurance dollars until the state licenses your captive.
Get one line wrong, and the review actuary or the Captive Insurance Section can stall your file for weeks, ask for a full re-filing, or deny it outright. Tennessee processes a clean application in about 30 days, but a messy one can drag on for months while your premium dollars sit on the table. This guide walks you through the form one section at a time, with real names, real numbers, and the exact mistakes that trip up first-time filers.
Here is what you will learn:
- 📋 What the agency captive application is and who has to file it
- 🗂️ Every document and number you must gather before you open the form
- ✍️ A line-by-line walkthrough of each section, with sample entries
- 👥 Three full examples following real agency owners through the form
- ⚠️ The costly mistakes that get applications held, plus how to dodge them
What the Form Is and Who Must File It
The Tennessee Captive Insurance Company License Application is the official request for a Certificate of Authority under the Tennessee Revised Captive Insurance Act, found at Tennessee Code Title 56, Chapter 13. The form tells the Department who owns the captive, what risks it will cover, how much money backs it, and who runs it day to day. The Captive Insurance Section reviews the form, and the Commissioner makes the final call on approval.
You must file this form if you own or control an insurance agency and want to form an agency captive or a producer-owned reinsurance company (PORC). A PORC is a captive that a broker or managing general agent uses to reinsure selected risks it produces, so it keeps the underwriting profit instead of handing it all to the fronting carrier, per IRMI’s definition. Any agency that wants to share in premium and profit, rather than collect a flat commission, is the core filer here.
The statute exists to make sure a captive can actually pay claims. The consequence of ignoring it is steep: operating an unlicensed insurer is an illegal act that can void your reinsurance agreement and expose you to fines. Picture Dana Reyes, who owns a 12-person agency and signs a quota-share treaty before she files; her fronting carrier can refuse to cede premium until her Certificate of Authority is in hand. A common myth is that an agency captive is “just a side account” you can open like a checking account, but it is a regulated insurance company with capital, board, and reporting duties.
Before You Start: Documents and Information You Need
Tennessee asks you to submit the application as separate PDF files by email, so gather everything before you open the form. Missing one item is the top reason a file sits in limbo. Below is your pre-filing checklist.
- Certificate of formation from the Secretary of State. You form the legal entity first, and the application needs the filed copy; without it, the Department cannot tie your form to a real company.
- Business plan and five-year pro forma financials. These show the captive can pay claims and stay solvent; a weak plan triggers an actuarial review and extra fees.
- Actuarial feasibility study. This justifies your premiums and loss picks; if it is missing, the reviewing actuary has nothing to opine on and the file stalls.
- Biographical affidavits for every officer, director, and owner. Tennessee uses its own (TN) Biographical Affidavit, and no substitute is accepted, so the wrong form means a do-over.
- Proof of minimum capital and surplus. You must provide it as an Irrevocable Letter of Credit, Depository Agreement, or Securities Account Control Agreement; cash promises alone do not count.
- Captive manager, actuary, and CPA designations. Tennessee requires you to name approved service providers on their designation forms, and an unnamed provider blocks approval.
- The fronting and reinsurance agreements. These define how premium flows from the carrier to your captive; missing terms make the risk picture impossible to confirm.
- The $675 application fee. This is due before approval, and the Department will not finish review without it.
- Federal Employer Identification Number (EIN). The captive needs its own EIN for tax and banking; using a personal or agency number causes mismatches.
- Organizational chart and ownership percentages. This maps who controls the captive and supports each biographical affidavit.
Pull together these items in one folder, named clearly, so each PDF can be submitted on its own. Marcus Webb, who runs a coastal property agency, lost two weeks because he sent one giant combined PDF instead of separate files the Index requires.
Where to Get the Form and How to Access It
You download the form for free from the Department’s Applications & Forms page. The main file is the “Captive Insurance Company License Application,” and the same page hosts the “Index for Captive Application,” which lists every required attachment in order. If you plan a cell structure instead of a standalone company, you use the “Protected Cell Captive Insurance Company Individual Cell Application” on that same page.
The application PDF requires Adobe Reader version 9 or higher to open and fill, so update your reader before you start. If you open it in a browser preview, the form fields may not save, and you will lose your entries. Aisha Bennett, forming a PORC for her health-benefits agency, typed an hour of answers into a browser tab and watched them vanish when she closed it.
Before you fill anything, the Department recommends you meet with the Captive Insurance Section first, as noted in its formation process. This early call lets a regulator flag structure problems before you spend money on actuaries. A misconception is that the meeting is optional red tape; in practice it is the cheapest way to avoid a rejected business plan, and skipping it often means a costly second filing.
Step-by-Step: How to Fill Out the Tennessee Captive Application Line by Line
The application is grouped into logical sections that mirror the Index for Captive Application. Fill each one in order, using the exact field labels printed on the form, and submit each major attachment as its own PDF.
Section 1: Name of the Proposed Captive Insurance Company
This field asks for the full legal name your captive will use. Enter the name exactly as it appears on your filed certificate of formation, in the same capitalization, and include the entity ending such as LLC or Inc. For example, Webb Coastal Re, LLC writes its name to match the Secretary of State record letter for letter.
A common edge case is using a “doing business as” name; do not, because the captive’s legal name must control. The most common mistake is shortening the name or dropping the entity type, which creates a mismatch with the formation certificate and forces the Department to bounce the file. People wrongly believe the name can be tweaked later for free, but a name change after licensing triggers a $90 amendment fee and fresh paperwork.
Section 2: Type of Captive and Lines of Business
This section asks what kind of captive you are forming and what risks it will insure or reinsure. Check the box that fits your structure, such as a pure captive or an agency-owned reinsurance arrangement, and list each line of business in plain terms. Dana Reyes checks the agency captive box and writes commercial property and general liability quota-share reinsurance.
A nuance: an agency captive almost always reinsures rather than writes direct, so describe the fronting relationship here, not a direct-issue model. The big mistake is listing lines you have no actuarial support for, because the reviewing actuary will strike them and question the whole plan. Many filers think they can “add lines later at no cost,” but expanding the plan of operations costs a $400 change fee and a new review.
Section 3: Principal Office and Records Location
Here you list the captive’s principal office address and where its books and records will be kept. Tennessee requires that all books, records, and information needed for an examination be located in Tennessee, so enter a Tennessee address. Aisha Bennett writes her captive manager’s Nashville office as the records location: 424 Church St, Nashville, TN 37219.
What if your agency sits in another state? You still need a Tennessee records location, usually through your captive manager, or the Department cannot license you. The common error is listing your out-of-state home office as the records site, which violates the in-state records rule and stops approval. A myth is that “cloud storage counts as anywhere,” but the Department expects a physical Tennessee point of contact for exams.
Section 4: Ownership and Organizational Structure
This field asks who owns the captive and in what percentages, with an attached organizational chart. List each owner, their stake, and how the captive ties back to your agency. Marcus Webb enters himself at 100% and attaches a chart showing his agency and captive under one holding company.
An edge case is shared ownership among several agency partners; list every owner above the threshold and match each to a biographical affidavit. The mistake that hurts most is leaving an owner off the chart, because the Department cross-checks owners against the affidavits and a gap signals hidden control. Filers often assume a minority partner “is too small to list,” but undisclosed ownership can be treated as a material omission.
Section 5: Officers and Directors (with Biographical Affidavits)
This section names every officer and director and requires a biographical affidavit for each one. Use the (TN) Biographical Affidavit for a standard agency captive, since the NAIC version is only for risk retention groups. Dana Reyes lists herself as President and her CFO as Treasurer, and submits a signed TN affidavit for each.
The affidavit asks for full legal name, employment history, and any regulatory or criminal disclosures, and you must answer every question. The top mistake is using the NAIC affidavit by accident, which the Department rejects because no substitute form is accepted. People wrongly think an old affidavit from another deal can be reused, but each captive application needs current, signed originals.
Section 6: Minimum Capital and Surplus
This field states how much capital and surplus backs the captive and how you will fund it. Enter the dollar amount and check the funding method, which must be an Irrevocable Letter of Credit, a Depository Agreement, or a Securities Account Control Agreement. Aisha Bennett enters $250,000 and attaches the Irrevocable Letter of Credit form unaltered.
A key nuance: you cannot edit the Department’s capital forms, because any change will not be accepted. The most damaging mistake is funding with a verbal promise or a plain bank balance instead of an approved instrument, which leaves the captive legally underfunded. A common misconception is that the minimum is the same for everyone; the Commissioner can set a higher figure based on your risk and plan, so confirm your number with the Captive Section first.
Section 7: Business Plan and Plan of Operations
This section is the narrative heart of the file and describes how the captive will operate over five years. Explain the risks, the fronting carrier, the reinsurance terms, projected premiums, expected losses, and your exit plan, and attach the five-year pro forma financials. Marcus Webb writes that his captive takes a 40% quota share of property premium from a named fronting carrier and projects $1.2 million in first-year ceded premium.
An edge case is a brand-new agency with no loss history; lean on industry data and a clear actuarial study to fill the gap. The biggest mistake is vague projections that the loss picks do not support, because the reviewing actuary will flag them and the file goes to extended review at your cost. Filers often believe a short plan is “cleaner,” but a thin plan reads as unprepared and almost always draws follow-up questions.
Section 8: Service Provider Designations
Here you name your captive manager, actuary, and CPA using the Department’s designation forms. Submit the Captive Manager Designation Form, the Actuary Designation Form, and the CPA Designation Form, each with the provider’s details. Dana Reyes names a licensed captive manager, a Fellow of the Casualty Actuarial Society as actuary, and an approved CPA firm.
A nuance: reserves must be certified by a qualified actuary, such as a member in good standing of the American Academy of Actuaries, so pick someone who meets that bar. The common mistake is naming an actuary who does not meet the credential rule, which voids the loss certification and blocks approval. People assume any accountant can serve, but the captive should use an approved CPA firm, especially if it elects annual audits for the favorable 5-year exam cycle.
Section 9: Signature, Certification, and Application Fee
The final section requires an authorized officer to sign and certify the application is true, and confirms the fee. Sign in the officer block, date it in MM/DD/YYYY format, and include the $675 application fee, which is due before approval. Aisha Bennett signs as President, dates it 06/02/2026, and notes the fee submission.
An edge case is signing by power of attorney; if an attorney signs, attach proof of authority or the Department may not honor the signature. The classic mistake is leaving the certification unsigned or undated, which makes the entire package incomplete and resets the clock. A myth is that the $675 fee is refundable if you withdraw, but Tennessee fees are nonrefundable under Section 56-4-101.
Three Filled-Out Examples Using Real Scenarios
These three examples follow common agency captive paths from start to finish. Each table shows what the named filer enters in the major sections of the form.
Example 1: Solo Agency Owner Forming a Pure Agency Captive
Dana Reyes owns a small commercial-lines agency and wants to share in the profit of the property business she places.
| Form Section | What Dana Enters |
|---|---|
| Name of Captive | Reyes Agency Captive, LLC |
| Type and Lines | Agency captive; commercial property and general liability quota-share reinsurance |
| Records Location | 424 Church St, Nashville, TN 37219 (captive manager’s office) |
| Ownership | Dana Reyes 100%, with org chart attached |
| Officers/Directors | President: Dana Reyes; Treasurer: CFO, both with TN affidavits |
| Capital and Surplus | $250,000 funded by Irrevocable Letter of Credit |
| Business Plan | 30% quota share of property premium, $800,000 first-year ceded premium |
| Signature and Fee | Signed as President, dated 06/02/2026, $675 fee included |
Example 2: Multi-Owner Brokerage Forming a PORC
Marcus Webb and two partners run a coastal property brokerage and form a producer-owned reinsurance company.
| Form Section | What Marcus Enters |
|---|---|
| Name of Captive | Webb Coastal Re, LLC |
| Type and Lines | PORC; coastal property reinsurance via quota-share treaty |
| Records Location | 424 Church St, Nashville, TN 37219 (captive manager) |
| Ownership | Marcus Webb 50%, two partners 25% each, with full chart |
| Officers/Directors | President, Secretary, Treasurer named; TN affidavit for each owner |
| Capital and Surplus | $500,000 funded by Securities Account Control Agreement |
| Business Plan | 40% quota share, named fronting carrier, $1.2M first-year ceded premium |
| Signature and Fee | Signed as President, dated 06/02/2026, $675 fee included |
Example 3: Benefits Agency Forming a Protected Cell
Aisha Bennett runs a health-benefits agency and uses a protected cell to test a captive with lower cost.
| Form Section | What Aisha Enters |
|---|---|
| Name of Cell | Bennett Benefits Cell within a sponsored captive |
| Type and Lines | Protected cell; group stop-loss reinsurance |
| Records Location | 424 Church St, Nashville, TN 37219 (cell sponsor) |
| Ownership | Aisha Bennett 100% of the cell’s participant shares |
| Officers/Directors | President: Aisha Bennett, with TN affidavit |
| Capital and Surplus | $150,000 cell capital by Depository Agreement |
| Business Plan | Stop-loss layer above $50,000, $400,000 first-year ceded premium |
| Signature and Fee | Signed as President, dated 06/02/2026, $675 fee included |
How to File the Completed Form
Tennessee accepts the agency captive application by email, and the steps are simple once your package is complete. You submit each document as a separate PDF, in the order set by the Index for Captive Application.
- Email submission. Send all PDFs to the Captive Insurance Section at captive.insurance@tn.gov, as directed on the Department’s how-to-form page. Keep your sent-mail confirmation as proof of filing.
- Application fee. Pay the $675 fee before approval; coordinate the payment method with the Captive Section when you submit. Save the receipt as proof.
- Formation step first. Before the application, file your formation documents with the Secretary of State after the Commissioner approves them, then include the formation certificate in your package.
- Processing time. Expect about 30 days from the date a complete package arrives, per the Department’s licensing information. Incomplete packages restart the clock.
- Issuance fee. Once approved, pay the $440 Certificate of Authority Issuance fee to receive your license.
Keep copies of every PDF, the email confirmation, and both fee receipts in one file. Marcus Webb keeps a dated folder so he can prove exactly when his complete package landed if any timing question comes up.
What Happens After You File
After your package arrives, the Captive Insurance Section reviews it and may forward it to an outside reviewing actuary. The actuary’s opinion is advisory only, and the Commissioner makes the final approval or denial, as the Department explains on its oversight page. If the actuary finds gaps, you may get questions or a request for more support, and you pay the actuarial review fees.
Once approved, the Department issues your Certificate of Authority after you pay the $440 issuance fee. Your captive then has ongoing duties, starting with an annual statement of financial condition due before March 15, verified by two officers. The annual statement filing fee is $515, and reserves must be certified by a qualified actuary each year.
A misconception is that licensing is the finish line, but the captive’s real life starts there. Captives that perform annual CPA audits earn a favorable 5-year examination cycle, while those that skip audits face a maximum 3-year cycle. Dana Reyes chooses annual audits so her captive stays on the lighter exam schedule and signals stability to her fronting carrier.
Mistakes to Avoid When Filling Out the Form
Each field on this form is its own chance to slip. Here are the errors that most often stall an agency captive application.
- Using a “doing business as” name instead of the legal name; the file mismatches the formation certificate and bounces.
- Editing the Department’s capital forms; any change is rejected and the file is treated as incomplete.
- Submitting one combined PDF; the Department needs separate PDFs and may return the package.
- Using the NAIC biographical affidavit for a non-RRG captive; only the TN affidavit is accepted.
- Leaving an owner off the org chart; the affidavit cross-check fails and signals hidden control.
- Listing lines of business with no actuarial support; the reviewing actuary strikes them and questions the plan.
- Funding capital with a verbal promise; the captive is legally underfunded and cannot be licensed.
- Naming an actuary who lacks the required credential; the loss certification is void.
- Putting an out-of-state records location; this breaks the in-state records rule and blocks approval.
- Forgetting the $675 fee before approval; the Department will not complete its review.
- Leaving the certification unsigned or undated; the package is incomplete and the clock resets.
- Skipping the pre-filing meeting with the Captive Section; structure problems surface late and cost a re-filing.
Do’s and Don’ts
These quick rules keep your application clean and moving.
- Do meet the Captive Insurance Section before filing, because early feedback prevents a rejected business plan.
- Do match your captive name to the formation certificate exactly, because mismatches stop the file.
- Do submit each attachment as a separate PDF, because the Index requires it and bundling slows review.
- Do use the unaltered TN forms for capital and affidavits, because edited or substitute forms are rejected.
- Do name qualified service providers, because reserve certification depends on the right credentials.
- Do keep proof of filing and fee receipts, because timing disputes need a clear record.
- Don’t add lines of business without actuarial support, because they will be struck and raise doubts.
- Don’t reuse old affidavits from other deals, because each application needs current signed originals.
- Don’t fund capital with anything but an approved instrument, because cash promises do not count.
- Don’t list an out-of-state records site, because Tennessee requires in-state records for exams.
- Don’t assume fees are refundable, because Tennessee captive fees are nonrefundable.
- Don’t treat licensing as the end, because annual statements and audits start right away.
Filing on Your Own vs. With a Captive Manager
Most agencies use a captive manager, but it helps to weigh both paths. The table below frames the trade-offs.
| Filing With a Captive Manager | Filing on Your Own |
|---|---|
| Pro: manager knows the Index and avoids rejections, saving weeks | Pro: lower upfront cost since you skip management fees |
| Pro: provides the required Tennessee records location and contact | Con: you must arrange an in-state records location yourself |
| Pro: lines you up with a qualified actuary and approved CPA | Con: you risk naming a provider who fails the credential rule |
| Pro: builds a defensible five-year business plan and pro formas | Con: a thin or unsupported plan draws extended actuarial review |
| Con: ongoing management fees add to annual cost | Con: errors can cost more than the fees you saved |
The clearest reason most agencies hire a manager is that Tennessee expects in-state records and qualified service providers, which a manager supplies. Aisha Bennett tried a do-it-yourself filing first, then hired a manager after her first package came back, and her second filing cleared in about a month.
FAQs
Do I use the NAIC biographical affidavit for my agency captive?
No. The NAIC affidavit is only for risk retention groups; agency captives use the Tennessee biographical affidavit, and the Department accepts no substitute form for officers, directors, and owners.
Do I write my captive’s legal name or a trade name in the name field?
No. You enter the full legal name exactly as filed with the Secretary of State, including the entity ending, not a “doing business as” or shortened name.
Do I need a Tennessee records location even if my agency is in another state?
Yes. Tennessee requires all books and records needed for an examination to be located in the state, usually through your captive manager’s office.
Do I have to fund capital with cash in a bank account?
No. You must use an Irrevocable Letter of Credit, Depository Agreement, or Securities Account Control Agreement, and you cannot edit those Department forms.
Do I list every owner on the organizational chart, even small ones?
Yes. Leaving any owner off creates a mismatch with the biographical affidavits and can be treated as a material omission that stalls approval.
Do agency captives write direct insurance or reinsurance?
No. An agency captive almost always reinsures business through a fronting carrier, so you describe the quota-share or treaty arrangement, not a direct-issue model.
Do I pay the application fee before or after approval?
Yes, before. The $675 application fee is due prior to approval of the captive or cell, and the Department will not finish review without it.
Do I get the application fee back if I withdraw?
No. Tennessee captive fees are nonrefundable under state law, so the $675 application fee is not returned if you cancel.
Do I need an actuary with a specific credential?
Yes. Reserves must be certified by a Fellow of the Casualty Actuarial Society, an American Academy of Actuaries member in good standing, or an individual approved by the Commissioner.
Do I submit all documents in one PDF file?
No. You submit each document as a separate PDF, in the order set by the Index for Captive Application, or the Department may return the package.
Do I file formation papers before or after the application?
Yes, before. You form the entity and obtain the formation certificate first, then include that certificate with your captive application package.
Do I have annual duties after I get the Certificate of Authority?
Yes. You file an annual statement before March 15 verified by two officers, pay the $515 filing fee, and certify reserves through a qualified actuary.
Do I have to perform annual audits?
No, but captives that audit annually with an approved CPA earn a 5-year exam cycle, while those that skip audits face a maximum 3-year cycle.
Do I have to meet with the Captive Section before filing?
No, it is not strictly required, but the meeting is the cheapest way to catch structure problems and avoid a rejected business plan and a second filing.
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