The Captive Dividend Request, known on paper as the Dividends and Distributions Request Form (Revised August 2016), is the document a captive insurance company files with its state insurance regulator to get permission before paying money or property back to its owners. In Tennessee, you submit it to the Captive Insurance Section of the Department of Commerce and Insurance, and the rule behind it lives in Tennessee Code 56-13-106.
This form sits between your captive and a payout. Get it right and your dividend clears in weeks. Get it wrong, or skip it, and you risk a delayed payment, a regulatory hold, or even action against your license under Tennessee Code 56-13-110. Tennessee now regulates over 700 risk-bearing entities and crossed $2.9 billion in captive premium in 2024, so the captive analysts who review these forms see a steady stream of them and notice the small errors fast.
Here is what you will walk away knowing:
- 📋 What each numbered field on the form asks and exactly what to write in it
- 🧮 How to fill out the cash versus other-property election and the valuation lines without tripping the analyst
- 🏢 Three full filled-out examples for a pure captive, a protected cell, and a risk retention group
- 📨 How to file with your assigned analyst, what it costs, and what proof to keep
- ⚠️ The mistakes that trigger a hold and how to dodge every one of them
What the Form Is and Who Must File It
The Captive Dividend Request is a two-page approval request. It tells the Tennessee Captive Insurance Section that your captive plans to send money or property to its owner, and it asks the Commissioner to sign off first. The form does not move the money. It only asks for the green light. The actual payment happens after you get written approval back.
Every type of captive licensed in Tennessee uses this same form. The top of the form lists six company types you can check: Pure, Protected Cell, Association, Risk Retention Group, Special Purpose Captive, and Branch. A pure captive owned by one parent files it. A protected cell distributing cell profits files it. A risk retention group returning surplus to its member-owners files it. The form is short, but the financial detail it asks for on page two is where filers spend most of their time.
You must file it because of Tennessee Code 56-13-106, which says no captive may pay a dividend out of, or make a distribution with respect to, capital or surplus without the prior approval of the Commissioner. In plain English, you cannot dip into the money that backs your policyholder promises and hand it to owners without asking first. The consequence of ignoring this is serious: an unapproved distribution can be treated as a violation of your license terms, and the Commissioner can suspend or revoke the captive’s certificate of authority. People often think a small or “routine” dividend is exempt. It is not. If the payment touches capital or surplus, the prior-approval rule applies.
Before You Start: Documents and Information You Need
Filling out this form goes fast when your numbers are ready and slow when you have to hunt for them. The form leans heavily on your most recent financial statements, so pull those first. Gather everything below before you open page one.
- Your captive’s exact legal name as it appears on your certificate of authority, because a name that does not match the Division’s records can cause the analyst to question whether the request is for the right entity.
- Your captive type (pure, protected cell, association, RRG, special purpose, or branch), because the box you check tells the analyst which capital rules apply to you.
- The proposed dividend amount, because this is the single number the whole review turns on, and an amount that drains surplus too far gets denied.
- The declaration date and the planned payment date, because the form asks for both and the gap between them is what gives the regulator time to respond.
- Whether the payout is cash or other property, because non-cash distributions require four extra valuation lines that cash payouts skip.
- A description, cost, fair market value, and basis of valuation for any non-cash property, because the analyst needs to confirm you are not undervaluing assets to dodge surplus limits.
- A 12-month history of prior dividends and distributions, because page two asks you to total every prior payout, and a missing entry understates how much capital you have already returned.
- Current-year and prior-year balance sheet figures: assets, liabilities, capital, retained earnings, net income, and total owners’ equity, because page two builds an adjusted-equity test from these numbers.
- The name and email of your assigned captive analyst, because the form says Submit to assigned analyst, and sending it to a general inbox can delay the hand-off.
If any item is missing, the analyst will email you for it, and the clock on your payment date keeps running while you scramble. Treat this list as a pre-filing checklist and check off all nine items before you type a single entry.
Where to Get the Form and How to Access It
You get the official form straight from the regulator, never from a third-party copy that might be out of date. In Tennessee, the Dividends and Distributions Request Form lives on the Captive Insurance Section’s applications and forms page. It is a fillable PDF, so you can type directly into it on your computer.
Always confirm the revision date. The current Tennessee version reads Revised August 2016 in the bottom corner of both pages. If your copy shows a different date or no date, you may be holding an old version, and an outdated form can bounce back to you. Download a fresh copy each time rather than reusing a saved file from a prior year.
Other domiciles host their own version of this form, and the field layout differs. Nevada, for example, posts a Non-RRG Captive Dividend Request on its Division of Insurance forms page and pairs it with a dividend analysis spreadsheet. The principle is the same everywhere: download the form from the state that licensed your captive, because a Tennessee captive filing a Nevada form, or the reverse, will be rejected. This article walks through the Tennessee form line by line, but the logic of each field maps closely to other states’ versions.
Step-by-Step: How to Fill Out the Dividends and Distributions Request Form Line by Line
The form has a header block, then six numbered items across page one, then a financial table on page two. Work through them in order. Each field below tells you what it asks, how to answer, a sample entry, an edge case, the mistake to avoid, and a myth to drop.
Header: Date
The top line asks for the date you are submitting the request. Write today’s date in MM/DD/YYYY format, the same day you send the form to your analyst. For example, Northwind Pure Captive, Inc. enters 06/02/2026 on the date line when its manager emails the request.
If you prepared the form a week ago but are only sending it today, use today’s date, not the prep date, because the analyst treats this as the receipt anchor. A common mistake is leaving this line blank, which makes it hard for the analyst to track how long the request has been pending and can push your file to the bottom of the queue. People wrongly believe this date is the dividend payment date. It is not. The payment date is item 3, and confusing the two creates a timeline that does not add up.
Header: Company Paying Dividend
This line asks which captive is making the payout. Enter the captive’s full legal name exactly as it appears on its Tennessee certificate of authority, using the same spelling, suffix, and punctuation. For a protected cell, name the cell and its sponsor so the analyst knows which balance sheet to pull, such as Series 7 of Cardinal Cell Captive, LLC.
If your captive recently changed its name, use the current approved name, not the old one, and make sure an address or name change form is already on file. The common mistake here is writing a parent company’s name instead of the captive’s name, which sends the analyst looking at the wrong entity and stalls the review. Filers sometimes think the “company paying dividend” means the recipient. It means the captive itself, the one whose surplus is being tapped.
Header: Company Type
This block asks you to check one of six boxes describing your captive: Pure, Protected Cell, Association, Risk Retention Group, Special Purpose Captive, or Branch. Check the single box that matches your license. Bluegrass Risk Retention Group checks the Risk Retention Group box, while a single-parent captive checks Pure.
If your captive holds an unusual designation, match it to the closest licensed category and note the detail in your cover email rather than checking two boxes. The mistake to avoid is checking the wrong type, because each type carries different capital and surplus expectations, and a mismatch invites questions about whether you understand your own structure. A myth here is that the type box is cosmetic. It is not, because RRGs face tighter scrutiny on member-owner distributions than a pure captive does.
Item 1: Amount of Proposed Dividend or Distribution
Item 1 asks how much you want to pay out. Enter the total dollar figure with a dollar sign and two decimals, such as $500,000.00. This is the number the entire review is built around, so make sure it matches the amount your board declared in its resolution.
If part of the payout is cash and part is property, enter the combined total here and break out the property in item 5. A frequent mistake is entering a “net” figure that already subtracts something, when the analyst expects the gross declared amount, which then fails to tie to your board minutes. Filers often assume a smaller amount avoids review. Under Tennessee Code 56-13-106, any dividend out of capital or surplus needs approval no matter how small, so size does not buy you an exemption.
Item 2: Date Proposed Dividend or Distribution Declared
Item 2 asks when your board formally declared the dividend. Write the date your board adopted the resolution, in MM/DD/YYYY format. For example, if the board of Northwind Pure Captive, Inc. voted on May 28, 2026, the manager enters 05/28/2026.
If the board approved an ongoing dividend plan rather than a single payment, use the date of that plan’s adoption and reference it in your cover note, because Tennessee Code 56-13-106 allows approval of an ongoing distribution plan. The mistake to avoid is entering a declaration date that comes after the payment date in item 3, which is impossible and signals a careless filing. People sometimes think the declaration date is the same as the filing date. They can differ, and the analyst reads them as two separate events.
Item 3: Date Established for Payment of Proposed Dividend or Distribution
Item 3 asks when you plan to actually pay the dividend. Enter the planned payment date in MM/DD/YYYY format, and leave the regulator enough runway to review and respond before that date arrives. A safe gap is several weeks out, so a request filed June 2 might list a payment date of 07/15/2026.
If you do not yet have a firm payment date, give a realistic target rather than leaving it blank, because the analyst needs a deadline to prioritize against. The most damaging mistake here is setting a payment date that is days away, since you cannot legally pay until you have written approval, and a tight date means you will likely pay late or pay early without consent. A dangerous myth is that filing the form equals approval. It does not. You must wait for the Commissioner’s written sign-off before any money moves.
Item 4: Type of Dividend or Distribution
Item 4 asks whether you are paying in Cash or Other Property. Check one box. Most captives check Cash and move on. If you check Other Property, you must complete all of item 5 next.
If your distribution mixes both, check Other Property and describe the property portion in item 5 while noting the cash portion in your cover note. The mistake to avoid is checking Cash but actually transferring an asset like a bond or real estate, because that hides a non-cash transfer the analyst must value, and it can look like you are skirting the valuation lines. Filers wrongly assume property distributions are treated the same as cash. They are not, because the regulator has to confirm the property’s value before it can judge the surplus impact.
Item 5: If Distribution Is Other Than Cash
Item 5 only applies when you checked Other Property in item 4, and it has four parts. Skip it entirely for cash dividends. When it applies, you must fill all four lines so the analyst can independently judge the value of what you are moving out of the captive.
5a. Description. Describe the property in concrete terms, such as 10,000 shares of XYZ Corp. common stock or commercial real estate at 123 Main St., Nashville, TN. Vague entries like “securities” force a follow-up. A common mistake is under-describing the asset, which delays the review while the analyst asks for specifics, and it can suggest you are hiding something. Filers think a short label is enough. The analyst needs enough detail to verify the asset exists and belongs to the captive.
5b. Cost. Enter the captive’s original book cost of the property, with a dollar sign and two decimals, such as $180,000.00. This is what the captive paid for it, not what it is worth today. A mistake here is entering market value in the cost line, which scrambles the gain or loss the analyst expects to see. People confuse cost with value, but the form asks for both on purpose so it can see the spread.
5c. Fair Market Value. Enter what the property is worth today, supported by a recent quote, appraisal, or statement, such as $240,000.00. This drives the surplus-impact calculation. The mistake to avoid is using a stale or self-estimated value, because an inflated value overstates the cushion left behind and an undervalued one can be read as manipulation. A myth is that you can just plug in book value. Fair market value must reflect current worth, not the number on your ledger.
5d. Basis of Valuation. State how you arrived at the fair market value, such as closing market price on 05/30/2026 for a listed stock or independent appraisal dated 05/15/2026 for real estate. This is the proof behind 5c. The mistake here is leaving it blank or writing “estimate,” which gives the analyst no way to confirm your number and almost guarantees a follow-up. Filers think their word is enough. The basis line exists precisely because the regulator will not take an unsupported value on faith.
Item 6 (Page 2): Dividends and Distributions Paid in Prior 12-Month Period
Item 6 asks you to list every dividend and distribution your captive paid in the prior twelve months, in a small table with columns for Date, Type, and Amount, then to enter the Total Dividends Paid in the Prior Twelve (12) Month Period. List each payout on its own row, then sum them in the total line. For example, Northwind Pure Captive, Inc. lists a single prior payout of 11/15/2025, Cash, $200,000.00 and totals $200,000.00.
The instruction note clarifies that this excludes distributions of the insurer’s own securities, so do not count those. If your captive paid nothing in the prior year, enter $0.00 in the total so the line is not left blank. The mistake to avoid is omitting a prior dividend, because the analyst can cross-check your annual report, and a missing payout understates how much capital you have already returned and undercuts your credibility. People wrongly believe only the current request matters. The 12-month history matters because the regulator judges the cumulative drain on surplus, not just one payment.
Page 2: Financial Summary Table
The bottom of page two is a financial grid with rows for Assets, Liabilities, Capital, Retained Earnings, Net Income, Total Owners Equity, Distribution, and Adjusted Owners Equity, split into Current Year and Prior Year columns. Pull these figures straight from your most recent statutory financial statements and enter them in whole dollars. The footnotes tell you that for the current year you include the proposed distribution requested, and that the Adjusted Owners Equity prior-year entry is not applicable.
Enter the proposed dividend in the Distribution row under the current year, then subtract it to show Adjusted Owners Equity, which is the cushion left after you pay. For example, if Total Owners Equity is $3,000,000.00 and the Distribution is $500,000.00, then Adjusted Owners Equity is $2,500,000.00. If your numbers do not tie to your filed annual report, the analyst will notice and ask, so reconcile before you submit. The mistake to avoid is showing an adjusted equity that falls below your required minimum capital and surplus, because that all but guarantees a denial under Tennessee Code 56-13-106, which conditions ongoing distribution approval on keeping surplus above set amounts. A myth is that the table is optional supporting detail. It is the heart of the analyst’s review, and an incomplete table sends the whole form back.
Three Filled-Out Examples Using Real Scenarios
Below are three named filers carrying the form from top to bottom. Each table shows what that filer enters in the form’s main sections.
Scenario 1: Northwind Pure Captive, a Routine Cash Dividend
Maria Lopez manages Northwind Pure Captive, Inc., a single-parent captive that had a profitable year and wants to return earnings to its parent in cash.
| Form Section | What Maria Enters for Northwind |
|---|---|
| Date | 06/02/2026 |
| Company Paying Dividend | Northwind Pure Captive, Inc. |
| Company Type | Pure (box checked) |
| 1. Amount of Proposed Dividend | $500,000.00 |
| 2. Date Declared | 05/28/2026 |
| 3. Date Established for Payment | 07/15/2026 |
| 4. Type of Dividend | Cash (box checked) |
| 5. If Other Than Cash | Left blank, not applicable |
| 6. Prior 12-Month Distributions | 11/15/2025, Cash, $200,000.00; total $200,000.00 |
| Financial Table (Current Year) | Total Owners Equity $3,000,000.00; Distribution $500,000.00; Adjusted Owners Equity $2,500,000.00 |
Scenario 2: Cardinal Cell Captive, a Non-Cash Property Distribution
Marcus Bell manages Series 7 of Cardinal Cell Captive, LLC, a protected cell that wants to distribute appreciated stock instead of cash.
| Form Section | What Marcus Enters for Series 7 |
|---|---|
| Date | 06/02/2026 |
| Company Paying Dividend | Series 7 of Cardinal Cell Captive, LLC |
| Company Type | Protected Cell (box checked) |
| 1. Amount of Proposed Distribution | $240,000.00 |
| 4. Type of Distribution | Other Property (box checked) |
| 5a. Description | 10,000 shares of XYZ Corp. common stock |
| 5b. Cost | $180,000.00 |
| 5c. Fair Market Value | $240,000.00 |
| 5d. Basis of Valuation | Closing market price on 05/30/2026 |
| 6. Prior 12-Month Distributions | Total $0.00 |
Scenario 3: Bluegrass Risk Retention Group, a Surplus Return to Members
Janet Pierce manages Bluegrass Risk Retention Group, an RRG that wants to return surplus to its member-owners after several strong years.
| Form Section | What Janet Enters for Bluegrass |
|---|---|
| Date | 06/02/2026 |
| Company Paying Dividend | Bluegrass Risk Retention Group |
| Company Type | Risk Retention Group (box checked) |
| 1. Amount of Proposed Dividend | $1,200,000.00 |
| 2. Date Declared | 05/20/2026 |
| 3. Date Established for Payment | 07/31/2026 |
| 4. Type of Dividend | Cash (box checked) |
| 6. Prior 12-Month Distributions | 12/01/2025, Cash, $600,000.00; total $600,000.00 |
| Financial Table (Current Year) | Total Owners Equity $9,000,000.00; Distribution $1,200,000.00; Adjusted Owners Equity $7,800,000.00 |
How to File the Completed Form
Tennessee keeps filing simple: the form says Submit to assigned analyst. That means you do not mail this to a general window or drop it in a public portal. You send it to the specific analyst assigned to your captive within the Captive Insurance Section.
- By email to your assigned analyst. This is the standard channel. Attach the completed fillable PDF plus your board resolution and any valuation support, and send it to the analyst’s state email address. If you do not know who your analyst is, the Captive Insurance Section’s main line is 615-741-3805, and the section sits at 500 James Robertson Parkway, Nashville, Tennessee 37243. There is no separate filing fee charged on the dividend request itself, and expect a review that runs a few weeks depending on how clean your numbers are.
- By mail, if requested. If your analyst asks for a paper copy, send it to the Captive Insurance Section, Davy Crockett Tower, 10th Floor, 500 James Robertson Parkway, Nashville, TN 37243. Use tracked mail so you have proof of delivery, and keep the tracking receipt.
Whatever channel you use, keep proof of filing: a copy of the sent email with its timestamp, the attached PDF, and any read receipt or analyst reply. Do not pay the dividend until the written approval lands in your inbox, because the prior-approval rule in Tennessee Code 56-13-106 is what protects your license.
What Happens After You File
Once your assigned analyst has the form, they review it against your most recent annual statement and your captive’s required capital and surplus. They confirm the math in the page-two table, check that the adjusted owners’ equity stays above your minimum, and verify the prior 12-month history matches their records. Clean filings move fast; filings with mismatched numbers generate an email asking for more.
If the analyst is satisfied, you receive written approval, and only then can you pay the dividend on or after the date in item 3. The Commissioner may approve an ongoing distribution plan rather than a one-off, but that approval is conditioned on keeping surplus above set thresholds at the time of each payment, per Tennessee Code 56-13-106. If the request would drop your surplus too low, the analyst can ask you to reduce the amount or deny it outright.
After payment, record the distribution in your books and report it on your next annual report so the numbers line up with what you filed here. A distribution paid without approval, or one that differs from what was approved, can expose the captive to license suspension or revocation under Tennessee Code 56-13-110. Keep the approval letter in your permanent file alongside the board resolution.
Mistakes to Avoid When Filling Out the Form
- Paying the dividend before you get written approval, which violates the prior-approval rule and puts your license at risk.
- Setting a payment date in item 3 only days out, which leaves no time for review and forces a late or unauthorized payment.
- Entering the parent company’s name instead of the captive’s name, which sends the analyst to the wrong entity and stalls the file.
- Checking the wrong company type box, which applies the wrong capital expectations and invites pointed questions.
- Entering a net dividend amount in item 1 instead of the gross declared figure, which fails to tie to your board minutes.
- Checking Cash when you are actually transferring property, which hides a non-cash transfer the analyst must value.
- Leaving item 5d, basis of valuation, blank, which gives the analyst no way to confirm your fair market value and triggers a follow-up.
- Omitting a prior payout from the item 6 history, which understates returned capital and undercuts your credibility.
- Showing an adjusted owners’ equity that falls below your required minimum capital and surplus, which all but guarantees a denial.
- Submitting figures that do not match your filed annual statement, which signals careless work and slows the whole review.
- Sending the form to a general inbox instead of your assigned analyst, which delays the hand-off and the clock keeps running.
- Reusing an outdated copy of the form, which can bounce back and cost you days you do not have.
Do’s and Don’ts
Do:
- Do download a fresh, current copy of the form each time, because reusing an old file risks an outdated version.
- Do file several weeks ahead of your planned payment date, because the regulator needs runway to review and respond.
- Do reconcile your page-two figures to your annual statement, because matching numbers speed approval.
- Do attach your board resolution and valuation support, because they answer questions before the analyst has to ask.
- Do keep proof of filing and the written approval, because they protect you if the timeline is ever questioned.
- Do send the form directly to your assigned analyst, because that is exactly what the form instructs.
Don’t:
- Don’t pay the dividend before written approval arrives, because that breaks the prior-approval rule and risks your license.
- Don’t guess at fair market value for property, because an unsupported figure draws scrutiny.
- Don’t leave any line blank, because gaps generate follow-up emails that delay you.
- Don’t enter a net or rounded-down amount to seem smaller, because the size of the dividend does not exempt it from review.
- Don’t assume filing equals approval, because the money cannot move until the Commissioner signs off.
- Don’t skip the prior 12-month history, because the analyst judges the cumulative drain on surplus.
Pros and Cons of Filing on Your Own vs. With Your Captive Manager
Most captives file this form through their captive manager, but an owner with a strong in-house finance team can file it directly. Here is how the two paths compare.
Pros of filing on your own (in-house):
- You save the manager’s fee for preparing and submitting the request, which adds up over repeated filings.
- You keep direct control of the timeline and can move the moment your board declares.
- You learn the form deeply, which helps you spot surplus issues earlier each year.
- You build a direct line to your assigned analyst, which can speed future filings.
- You keep sensitive financial detail inside your own team.
Cons of filing on your own (in-house):
- You may misread the capital and surplus rules and request an amount that gets denied.
- You carry full responsibility if a number fails to tie to your annual statement.
- You lack the manager’s relationship and shorthand with the analyst, which can slow review.
- You risk filing an outdated form or missing a required attachment.
- A mistake on the prior-approval rule can expose your license, a risk a seasoned manager helps you avoid.
FAQs
Do I need approval before paying any dividend from my captive?
Yes. Under Tennessee Code 56-13-106, no captive may pay a dividend out of capital or surplus without the Commissioner’s prior approval, regardless of how small the payment is.
Do I write the captive’s name or the parent’s name in the “Company Paying Dividend” line?
No. You write the captive’s full legal name, not the parent or the recipient, because that is the entity whose surplus is being tapped and reviewed.
Do I have to complete item 5 for a cash dividend?
No. Item 5 only applies when you check Other Property in item 4, so cash dividends skip all four valuation lines.
Do I enter book value or current value in line 5c, Fair Market Value?
No. Line 5c asks for current worth, not book value; book cost goes in line 5b, and 5c must reflect what the property is worth today.
Do small dividends skip the prior 12-month history in item 6?
No. You report every prior dividend and distribution from the past twelve months, because the regulator judges the cumulative drain on surplus, not one payment.
Do I file this form with a general state inbox?
No. The form says Submit to assigned analyst, so you send it to the specific analyst assigned to your captive within the Tennessee Captive Insurance Section.
Do all captive types use the same form?
Yes. Pure, protected cell, association, risk retention group, special purpose, and branch captives all use the same Dividends and Distributions Request Form and check the matching type box.
Do I pay a filing fee for the dividend request?
No. Tennessee does not charge a separate fee on the dividend request itself, though your captive still owes its regular premium taxes and annual fees.
Do I include the proposed dividend in the page-two financial table?
Yes. The footnote directs you to include the proposed distribution in the current-year column, which is what produces the adjusted owners’ equity figure.
Do I have to wait for written approval before paying?
Yes. Filing is only a request; you may not move any money until the Commissioner’s written approval arrives, or you risk action against your license.
Do I use today’s date or the payment date on the top “Date” line?
No. The top line is the submission date, today’s date, while the payment date belongs in item 3, and confusing the two creates a timeline that does not add up.
Do other states use this exact form?
No. Each domicile posts its own version, such as Nevada’s Non-RRG Captive Dividend Request, so you must use the form from the state that licensed your captive.
Do I need a board resolution to file?
Yes. The board must declare the dividend first, and attaching the resolution lets the analyst confirm the amount and declaration date in items 1 and 2.
Do I round the financial figures or use exact dollars?
Yes. Use the exact figures from your most recent statutory financial statements so the page-two table ties cleanly to your filed annual report.
Related reading
- How to Fill Out the North Carolina DOI Captive Insurance Application + FAQs
- How to Fill Out the Agency Captive Application (w/Examples) + FAQs
- How to Fill Out the Montana Captive Insurance Company Application + FAQs
- How to Fill Out the Pure Captive Insurance Application (w/Examples) + FAQs
- How to Fill Out the South Carolina Captive Insurance Application + FAQs
- How to Fill Out the Tennessee Captive Insurance Company Application + FAQs