Producer-Controlled Insurer Information Report Form
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1PRODUCER-CONTROLLED INSURER INFORMATION REPORT FORM (NOTE: Complete only Section l or Section ll )
December 31, 2015
Calendar Year Ending
Instructions: All licensed property and casualty and title 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 N.J.S.A. 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
forms are due annually on or before April 1st of each year.
SECTION I
not
(To be completed by Insurers that are
Producer-Controlled)
I certify that the
___________________________________________________________ NAIC # ____________
(name of insurer)
________________________________________________ State of Domicile:
_____________
Address of Insurer)
is not issuing any property and casualty insurance coverages that are or may be reportable pursuant to the provisions of
N.J.S.A. 17:22D-1 et.seq. and N.J.A.C. 11:2-37.1 et.. seq.
Authorized signature : ________________________________________
Title : ___________________________________
Print Name : ________________________________________________
Date : __________________________________
SECTION II
that are
(To be completed insurers
Producer-Controlled)
(A separate Report Form should be completed and filed for each controlling producer.)
December 31, 2015
Calendar Year Ending:
Name of Reporting Insurer: __________________________________________
NAIC #: ________________
Address: _________________________________________________________ State of domicile: __________
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:
a)
Net premiums written:
$_________________
b)
Commission paid:
$__________________
c)
Percentage:
___________________ %
MUST
8.
NOTE: PRODUCER CONTROLLED INSURERS
ATTACH THE INFORMATION REQUIRED PER 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. ARE (IS) THE REQUIRED ACTUARIAL OPINION(S) ATTACHED? (Yes or NO) ___________
9. We have notified our controlling producer(s) of the requirements of N.J.S.A. 17:22D-1 et seq. and N.J.A.C. 11:2-37.1 et seq.
I certify that the above information is accurate and complete.
Authorized signature : __________________________________________________ Title : ___________________________________
Print Name : ________________________________________________________ Date : __________________________________
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