Form E-Ii - Industrial Insureds Premium Receipts Report - 2015 Page 3
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5Complete Name of Insured
SECTION D: QUALIFIED RISK MANAGER. Indicate which of the following federal and state qualifications
your risk manager satisfies.
If "None," you must cease procuring insurance directly from non-admitted insurers.
10 years of relevant experience (Line D10).
None.
7 years of relevant experience (Line D10) AND at least one relevant professional designation (Lines
D5 - D9).
A bachelor's degree from an accredited college/university in risk management, business
administration, finance, economics or another field determined by the director of insurance to
demonstrate competence in risk management AND EITHER:
3 years of relevant experience (Line D10) OR
At least one relevant professional designation (Lines D5 - D9).
A graduate degree from an accredited college/university in risk management, business administration,
finance, economics or another field determined by the director of insurance to demonstrate
competence in risk management (Line D4).
D1 - Last Name
First Name
Middle Name
Jr./Sr./II/III/etc.
D2
Relationship of qualified risk manager to the insured
Employee
Third-party consultant
D3
Major/field for bachelor's degree:
College/university:
Graduation mo/yr
D4
Major/field for graduate degree:
College/university:
Graduation mo/yr
D5
Does the risk manager hold a designation as a Chartered Property and Casualty
Yes
No
Underwriter issued by the American Institute for CPCU/Insurance Institute of
America?
D6
Does the risk manager hold a designation as an Associate in Risk Management
Yes
No
issued by the American Institute for CPCU/Insurance Institute of America?
D7
Does the risk manager hold a designation as Certified Risk Manager issued by
Yes
No
the National Alliance for Insurance Education & Research?
D8
Does the risk manager hold a designation as a RIMS Fellow issued by the Global
Yes
No
Risk Management Institute?
D9
Does the risk manager hold any other designation, certification or license that
Yes
No
shows the risk manager possesses competency to act as the insured's risk
manager? If "Yes," describe below:
_________________________________________________________________
D10
In this section, report the risk manager's relevant experience during the past 10 years. For each job,
use the "Code" column to identify whether the experience involved [A] risk financing, [B] claims
administration, [C] loss prevention, [D] risk and insurance coverage analysis, or [E] purchasing
commercial lines of insurance. Provide additional signed and dated sheets if necessary.
Code
Name of Employer
Job Title
Start
(mm/yy)
End
(mm/yy)
Page 3 of 5
Industrial Insureds Premium Receipts Report
Form E-II (v20150224)
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