N.J. Admin. Code § Tit. 11, ch. 2, subch. 37, app A

Current through Register Vol. 56, No. 21, November 4, 2024

Appendix A

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

N.J. Admin. Code Tit. 11, ch. 2, subch. 37, app A

Amended by R.1996 d.3, effective 1/2/1996.
See: 27 New Jersey Register 3278(b), 28 New Jersey Register 152(b)..