Certified Public Accountant Designation Form For Captive .

500 James Robertson ParkwayCaptive Insurance SectionNashville, Tennessee 37243615-741-3805Certified Public Accountant Designation Formfor Captive Insurance CompaniesSubmit completed form to captive.insurance@tn.govFIRM INFORMATION1. Firm Name *2. Firm AddressAddress Line 1 (no PO BOX): *Address Line 2:City: *State: *Postal Code: *CountryPhone No.: *Secondary Phone:Firm Website: *Required Field *IN-1993Page 1 of 5RDA 2226

500 James Robertson ParkwayCaptive Insurance SectionNashville, Tennessee 37243615-741-3805Certified Public Accountant Designation Formfor Captive Insurance CompaniesINDIVIDUAL INFORMATIONEach Engagement Partner responsible for an Auditor’s Report issued for a Tennessee-domiciled CaptiveInsurance Company must complete pages 2 through 6.Attach the following documents and information to this application when submitted.1.2.3.4.5.A completed biographical affidavit,A copy of your resume or curriculum vitae,A certified copy of any disciplinary orders issued involving you from any professional organization towhich you belong,Copies of all professional licenses you hold, andCopies of the resumes or curriculum vitae of all persons who would be employed or assigned auditingwork by you.1. NameFirst Name: *Last Name: *Position/Title: *Employment Period: *Email Address: *Phone: *2. Education and Degrees: Please list those institutions from which you graduated.College Name: *City: *State: *Degree: *Field of Study:Required Field *IN-1993Page 2 of 5RDA 2226

500 James Robertson ParkwayCaptive Insurance SectionNashville, Tennessee 37243615-741-3805Certified Public Accountant Designation Formfor Captive Insurance Companies3. Do you have an ACI designation? *YesNo4. List your current certified public accountant (“CPA”) license information below:State: *Issue Date: *License Number: *5. I ndicate, by specific dates, all insurance and/or captive auditing experience you havefor the past 15 years.Beginning: *Ending: *Describe: *6. List the Captive Account(s) you will be auditing. *7. H ave you ever been arrested, or indicted for and/or convicted of any crime oroffense other than a minor traffic violation (e.g. speeding, parking ticket)? *YesNoIf “Yes,” please explain and add attachments as needed:8. D o you control directly or indirectly, or own legally or beneficially the outstandingstock of any insurer? *YesNoIf “Yes,” please explain and add attachments as needed:Required Field *IN-1993Page 3 of 5RDA 2226

500 James Robertson ParkwayNashville, Tennessee 37243Captive Insurance Section615-741-3805Certified Public Accountant Designation Formfor Captive Insurance Companies9. Do you currently hold or have you ever held licenses relating to insurance? *YesNoIf “Yes,” please provide the following information: *State *Issue Date *Expiration Date Agency *Type *License No./Designation *10. Have you ever had a license or privilege refused or revoked by any insuranceregulatory agency? *YesNoIf “Yes,” please explain and add attachments as needed:11. Have you ever had a certified public accountant (CPA) license suspended, placed onprobation, or revoked? *YesNoIf “Yes,” please explain and add attachments as needed:12. Will you assign captive auditing functions only to employees or individuals that havea minimum or two years insurance auditing experience? *YesNoIf “Yes,” please explain and add attachments as needed:Required Field *IN-1993Page 4 of 5RDA 2226

500 James Robertson ParkwayNashville, Tennessee 37243Captive Insurance Section615-741-3805Certified Public Accountant Designation Formfor Captive Insurance CompaniesCERTIFICATIONI hereby certify and declare, under penalties of perjury:1.That I have been authorized by the applicant management firm herein to complete this “Certified PublicAccountant Designation Form for Captive Insurance Companies” (Designation) and to make thiscertification and declaration;2.That the information provided in this Designation and the documents attached hereto and included aspart of the Designation have been examined by me and are, to the best of my knowledge, informationand belief, true, correct, and complete;3.That I am aware that should investigation at any time disclose any such misrepresentation or falsestatement or information, my firm will be disqualified from further consideration as a certified publicaccountant for captive insurance companies;4.That I authorize each of the references, associations or licensing or supervising agencies of state,federal or foreign governments to give the Tennessee Department of Commerce & Insurance anyprivate or confidential information concerning the management firm that is applying for approval; and5.That I release the Tennessee Department of Commerce & Insurance, its employees and authorizedagents, or any other state, federal or foreign government agency that receives information requestedas part of this Designation, from any civil or criminal liability arising under the Federal Rights andPrivacy Act or other applicable State or laws of a foreign jurisdiction.Dated this Day of , 20Printed Name of Officer/Principal *Signature of Officer/Principal *Notary:Notary Public Embosser or BlackInk Rubber Stamp SealCounty:State:Subscribed and sworn before methisday ofNotary Public SignatureMy commission Expires on:, 20Notary Public Name (Printed)Page 5 of 5Required Field *IN-1993RDA 2226

Copies of the resumes or curriculum vitae of all persons who would be employed or assigned auditing. work by you. Required Field * IN-1993 Page 2 of 5 RDA 2226. Captive Insurance Section. . Accountant Designation Form for Captive Insurance Companies” (Designation) and to make this