Section 38.2-1342 Report - Commonwealth Of Virginia Page 2
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3SECTION II
To Be Completed by Any Insurer That Is A Producer-Controlled Insurer
NOTE: Insurers completing Section II shall prepare and attach as Exhibit A a listing identifying each
Controlling Producer. For each producer the listing shall show: (i) name, (ii) complete mailing address,
(iii) the aggregate amount of gross written premium on business placed by the producer with the Insurer
during the most recent calendar year, and (iv) the percentage such amount represents of the Insurer's
total admitted assets as reported in the annual statement filed as of December 31.
___________________________________________________ is a "Controlled Insurer" (Insurer), as
(Name of Insurer)
defined by the provisions of the Act, and responds as follows:
To each question, respond Yes, No or N/A (not applicable), whichever is most appropriate.
YES NO N/A
1. Has the Insurer attached an Exhibit A, as prescribed by the instructions
to this form, fully disclosing the identity of each Controlling Producer
with whom it transacts business?
_____ _____ _____
2. Has the Insurer notified all such Controlling Producers of the requirements
of the Act?
_____ _____ _____
3. If the Insurer is domiciled in Virginia, has it complied with all of the
provisions of the Act?
_____ _____ _____
4. If the Insurer is not domiciled in Virginia, can it demonstrate substantial
compliance with the provisions of the Act?
_____ _____ _____
SECTION III
To Be Completed by Insurers that are NOT Producer-Controlled
__________________________________________________ is not issuing any property or casualty
(Name of Insurer)
insurance coverages that are or may be reportable in accordance with the provisions of the Act.
Section 38.2-1342 Report
Page 2 of 3
R08 (10/16)
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