Captive Liability Quick Review Questionnaire

Captive Liability Quick Review Questionnaire

A practical tool to identify captives that may warrant a closer ICML / ICPL review
Purpose: This quick review helps identify captives whose structure, governance, operations, fronting relationships, or daims activity may create management and professional liability exposures worth discussing. A yes answer does not mean coverage is needed. It simply means a closer review may make sense.
Contact and Captive Information
Captive Name
Domicile
Contact Name
Title
Organization
Email
example@example.com
Phone
Format: (000) 000-0000.
Captive Type
Website
Current Broker / Advisor
Preferred Follow-up
Renewal / Review Timing
Captive Structure
Please check all that apply:
Captive Structure Options
Quick Review Questions

Quick Review Questions

Rows	Yes	No	Comments I Notes
Does the captive have its own board of directors, officers, trustees, managers, or governing committee?
Does the captive have multiple owners, members, participants, shareholders, cells, or insureds?
Does the captive issue policies, certificates, endorsements, or other coverage documents?
Does the captive handle claims or oversee claims handled by a TPA or other service provider?
Does the captive use outside service providers such as a captive manager, TPA, broker, MGA, actuary, reinsurer, or fronting carrier?
Does the captive participate in a fronting arrangement?
Has the captive experienced material collateral increases, collateral disputes, reserve disputes, reinsurance disputes, regulatory inquiries, litigation, arbitration, or claims involving the captive during the past five years?
Does the captive write third-party, customer, vendor, association, or unrelated business?
Is the captive a group captive, association captive, RRG, PCC, SCC, or other multi-party structure?
Does the captive have employees or sponsor, administer, or have responsibility for any employee benefit plan?

Current Coverage
Please check any coverages currently purchased by the captive, if known:
Optional Review Request
Would you like Rockwood to provide a complimentary review of the captive's current management and professional liability structure?
Would you be willing to share current coverage information for review?
If yes, what can be provided?
Additional comments or questions:
Disclaimer: This review is intended solely as an educational and risk-identification tool. It is not legal, tax, accounting, or insurance coverage advice. Any insurance discussion should be based on the captive's specific structure, operations, and currentinsurance program.
Mark Lann | Executive Vice President | Rockwood Programs, Inc. | 786-412-4131 | mark.lann@rockwoodinsurance.com
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