New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 2 - INSURANCE GROUP › Subchapter 37 - PRODUCER-CONTROLLED INSURERS › Appendix A

Current through Register Vol. 56, No. 14, July 15, 2024
PRODUCER-CONTROLLED INSURER INFORMATION REPORT FORM
Calendar Year Ending December 31, ...
Instructions: All licensed property and casualty insurers domiciled in New Jersey, or domiciled in another state that is not a NAIC "accredited state" having in effect a law substantially similar to 17:22D-1 et seq., are required to complete annually either Section I or Section II of this form. Section I certifies that the requirements of New Jersey law have been reviewed and there is no controlling producer information to be reported. Section II should be completed for each producer who "controls" a reporting insurer. Completed reporting forms are due annually, on or before April 1 of each year.
SECTION I
To be completed by Insurers that are not Producer-Controlled
I certify that
.....................................................................
(Name of Insurer)
.....................................................................
(Address of Insurer)
is not issuing any property and casualty insurance coverages that are or may be reportable pursuant to the provisions of 17:22D-1 et seq. and 11:2-37.1 et seq.
.........................
...................................................
Date
Authorized signature
...................................................
Title
SECTION II
To be completed by Producer-Controlled Insurers
(A separate Report Form should be completed and filed for each controlling producer.)
Calendar Year Ending December 31, ...
Name of Reporting Insurer:
.....................................................................
Address:
.....................................................................
Name of Controlling Producer:
.....................................................................
Address:
.....................................................................
1.
Insurer's admitted assets as of September 30 of
$ .........
calendar year pursuant to N.J.S.A. 17:22D-3a:
2.
Gross premiums written, calendar year:
$ .........
3.
Percentage that gross premiums written represent of
..........%
admitted assets:
4.
Net premiums written, calendar year:
$ .........
5.
Amount of commissions paid to controlling producer,
$ .........
calendar year:
6.
Percentage that commissions paid represent of net
..........%
premiums written:
7.
Comparable amounts and percentage paid to
noncontrolling producers for placement of the same
kinds of insurance:
Net premiums written:
$ .........
Commissions paid:
$ .........
Percentage:
..........%
8.
Attach the information required by N.J.S.A. 17:22D-3e: An opinion of an
independent casualty actuary reporting loss ratios for each line of
business written and attesting to the adequacy of loss reserves
established for losses incurred and outstanding as of year-end,
including losses incurred but not reported, on business placed by the
controlling producer.
9.
We have notified our controlling producer(s) of the requirements of
17:22D-1 et seq. and 11:2-37.1 et seq.
I certify that the above information is accurate and complete.
.........................
...................................................
Date
Authorized signature
...................................................
Title