Foreign Liability Risk Retention Group Registration - State of

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					                                      STATE OF WYOMING

                               DEPARTMENT OF INSURANCE

            FOREIGN LIABILITY RISK RETENTION GROUP REGISTRATION

       We, the undersigned, President (or Chief Executive Officer) and Secretary of the Liability

Risk Retention Group identified herein do hereby state and affirm that:

1.     Name of Liability Risk Retention Group (must include phrase "Risk Retention Group"):




2.     FEIN:                                   NAIC Number:

3.     Domicile of Liability Risk Retention Group. Attach an original copy of the Certificate of

       Authority, Articles of Incorporation, Letter of Authorization or other proof of domicile.

       State or Location:

       Date:

4.     Principal Place of Business:

       Address:




       Telephone:

       Contact Person:

5.     States of Chartering or Licensure or Certification as to capitalization requirements if

       chartered under the laws of Bermuda or the Cayman Islands before January 1, 1985 (use

       and attach additional paper, if necessary):

       State:

       Date:


       State:

       Date:


       State:

       Date:

6.     Attached hereto and incorporated herein by this reference is a copy of the Liability Risk

       Retention Group's plan of operation or feasibility study from which the following

       information is extracted.      (Does not apply to any line or classification of liability

       insurance which was defined in the Product Liability Risk Retention Act of 1981 before




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October 27, 1986 and was offered before such date by a risk retention group chartered

and operating for not less than three (3) years before such date).

a.     Management and officers of the Liability Risk Retention Group consists of (use

       and attach additional paper, if necessary):

       Name:

       Title:

       Address:


       Name:

       Title:

       Address:


       Name:

       Title:

       Address:


       Name:

       Title:

       Address:


       Name:

       Title:

       Address:

b.     Has the Liability Risk Retention Group, its management, or any officers or agents

       thereof ever had its (their) license to conduct any aspect of insurance business

       suspended or revised or is currently subject to disciplinary investigations or other

       similar action?

       _____ yes                  _____ no

       If yes, who?      Name:

                         Title:

                         Address:



                         State in which action filed:

                         Date of action:

c.     Has the Liability Risk Retention Group, its management, or any officers or agents

       thereof ever plead to or been found to have engaged in any activity marked by



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     manipulation of assets, accounts or reinsurance, misappropriation or conversion of

     funds, bad faith or fraud?

     _____ yes       _____ no

     If yes, who?    Name

                     Title:

                     Address:



                     State and Court in which Action filed:



                     Date of Action:

d.   Lines and classifications of liability insurance coverage to be provided as defined

     in Chapter 15, Section 1.3 (d) of the Wyoming Insurance Department Regulations

     pertaining to the Wyoming Risk Retention Act:




e.   Limits of liability including per occurrence by line and classification:




f.   Range of deductibles and self-insured retention limits which may be available by

     line and classification:




g.   Solicitation of member insureds will be conducted through:                         direct

     sales,             licensed agents/brokers.

h.   Claims will be adjusted:                 in-house,             by licensed independent

     adjusters.

     Claims supervisor:         Name:

                                Title:




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                                     Address:



                                     Telephone:

7.   Concerning its organization, membership and qualifications as a Liability Risk Retention

     Group under W.S. ' 26-36-103(a)(xi) of the Wyoming Risk Retention Act the

     undersigned officers verify that:

     a.     The primary activity for which this Liability Risk Retention Group was organized

            and in which it is engaged is the assumption and spreading of all or a portion of

            the liability exposure of its members. Attached hereto and incorporated herein by

            this reference is a copy of the group's articles and bylaws certified by the public

            official with whom the originals are on file.

     b.     (Check one)

            _____ The owners of this Liability Risk Retention Group consist of only persons

            who comprise the membership of the Liability Risk Retention Group and who are

            provided insurance by the group;

                                                 or

            _____ The sole owner is
                                                                      (name)
            an organization located at
                                                                      (address)


            which has as its members only persons who are provided insurance by such group.

     c.     The members of this Liability Risk Retention Group are engaged in businesses or

            activities similar or related with respect to the liability of which such members are

            exposed by virtue of any related, similar or common business, trade, products,

            services, premises or operations as described herein (give general description of

            business or activities engaged in by group members and the similarities or

            relationships of the liabilities):




     d.     This Liability Risk Retention Group shall not solicit or sell insurance to any

            person who is not eligible for membership in the group. Attached hereto and

            incorporated herein by this reference are copies of all marketing materials which

            the Liability Risk Retention Group intends to use in this state.

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8.      Attached hereto and incorporated by this reference is a copy of each liability insurance

        policy this Liability Risk Retention Group intends to market and write in this state.

9.      Attached hereto and incorporated by this reference is a copy of this Liability Risk

        Retention Group's most recent annual financial statement, submitted to the group's state

        of domicile, certified by an independent public accountant and containing a statement of

        opinion loss and loss adjustment expense reserves made by a member of the American

        Academy of Actuaries or a qualified loss reserve specialist.

10.     Attached hereto and incorporated by this reference is a copy of each examination of this

        Liability Risk Retention Group as certified by the commissioner or public official

        conducting the examination.

11.     Attached hereto and incorporated by this reference is a copy of the most current annual

        statement filed on the NAIC annual statement blank.

12.     Attached hereto and incorporated by this reference is a certified copy of the resolution of

        the Liability Risk Retention Group's Board naming and registering the insurance

        commissioner as its agent for purposes of receiving service of process and legal

        documents.



We do hereby swear and affirm that the aforementioned statements and information are true and

correct this           day of                        ,       .




                                              President or Chief Executive Officer



                                              Secretary


Sworn before me this             day of                                ,      .


Notary Public

My commission expires:




                                                 5 Form RR3602 (rev. 7/99) Rr3602.doc - Internet Word60

				
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