APPLICATION REQUIREMENTS FOR LICENSURE AS A
REINSURANCE INTERMEDIARY
§33-2-1701 through §33-2-1709, Montana Code Annotated
1) Please complete the application form (copy enclosed).
2) If a partnership, corporation, or association, please include a copy of the partnership agreement,
articles of incorporation, or articles of association.
3) Submit a biographical affidavit for each individual, member, officer, or owner of the applicant and
each person to be authorized to act under the license.
https://content.naic.org/sites/default/files/ucaa-industry-naic-biographical-affidavit.pdf
4) Submit a signed copy of each written contract which includes a cover sheet identifying page number
and specific section or paragraph that demonstrates compliance with provisions required under
Section 33-2-1702 (for brokers) or 33-2-1705 (for managers), MCA.
5) Provide evidence that a fidelity bond is maintained in the amount not less than $50,000 for the
protection of each reinsurer (applies to managers only).
6) Provide evidence that a policy for errors and omissions is maintained in an amount not less than
$100,000 (applies to managers only).
7) Provide a brief explanation of your plan of operation for Montana.
8) If applicant is a resident and an individual, partnership, or association, file a certified copy of your
Certificate of Assumed Business Name obtained from the Montana Secretary of State.
9) Please provide an audited balance sheet and income statement for the most recent complete
calendar or fiscal year.
10) If applicant is a nonresident, file a statement from your state of domicile insurance department
stating whether any taxes, licenses, fees, or other material obligations, prohibitions, or restrictions
would be imposed upon a like Montana applicant. Montana laws are retaliatory. The same fee
charged by your state of domicile for a reinsurance intermediary license must be included in this
application.
11) Complete a service of process form (nonresidents only).
https://content.naic.org/sites/default/files/ucaa-industry-uniform-consent-service-process.pdf
406.444.2040
840 Helena Avenue
Helena MT 59601
...
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APPLICATION FOR REINSURANCE INTERMEDIARY LICENSE
1. Name
of Applicant: _________________________________________________________________________
(Name under which business is to be transacted)
2. Pri
ncipal Administrative Office Address:
________________________________________________________________________________________
City Stat
e Zip Phone Number
3. Mailing Address (if different from above)
City State Zip
4. FEIN #:
5. Facsim
ile #: __________ Email address
6. Type
of Business Organization:
□ Association
□ Corporation
□ Domestic
□ Foreign (state of incorporation, if applicable _____________
□ Individual
□ Partnership
7. Type
of License Requested:
□ Reins
urance Intermediary – BROKER
□ Reinsurance Intermediary – MANAGER
8. Names
of all insurance companies, licensed in Montana, with whom you currently hold a contract to act as an
intermediary:
_____________________________________________________________________
_________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
9. Giv
e full names and addresses of all members, or officers and Directors, or owners of the applicant.
FULL NAME TITLE ADDRESS
406.444.2040
840 Helena Avenue
Helena MT 59601
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10. Give name of all persons who will be authorized by applicant to act under the certificate and the relationship of each to
applicant.
NAME:__________________________________ RELATIONSHIP TO APPLICANT:__________________________
NAME:__________________________________ RELATIONSHIP TO APPLICANT:__________________________
NAME:__________________________________ RELATIONSHIP TO APPLICANT:__________________________
NAME:__________________________________ RELATIONSHIP TO APPLICANT:__________________________
11. Does the applicant agree that, if licensed is issued, only those persons named in this application will transact
insurance under this license? □ YES □ NO
12. Nam
e of Application Contact Person:
Phone Number:
DO
YOU, AS APPLICANT, AND ALL PERSONS NAMED (IN ITEMS NO. 8 AND 9 ABOVE) AGREE AS FOLLOWS:
1. To obtain a written contract betw
een you and each insurer as required under Section 33-2-1702 or 33-2-1705, MCA,
and to retain such agreement for its duration and for 10 years thereafter? □ YES □ NO
2. To contain in the required written contract provisions which include the requirements of 33-2-1702 or 33-2- 1705 insofar
as they relate to the functions performed by you? □ YES □ NO
3. To maintain in accordance with prudent standards of insurance recordkeeping, adequate books and records of all
transactions between you, the insurers, and the insured persons, for the duration of the required written contract and
for 10 years thereafter? □ YES □ NO
4. To maintain a policy on errors and omissions in an amount not less than $100,000? (Managers only)
□ YES □ NO
5. Mai
ntain a fidelity bond for the protection of the reinsurer in an amount no less than $50,000? (Managers only)
□ YES □ NO
DATE:___________________ ______________________________________________
OFFICER AND TITLE (PRINT)
______________________________________________
OFFICER SIGNATURE
406.444.2040
840 Helena Avenue
Helena MT 59601
...
csimt.gov
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