Form Not Assigned Not Assigned Application/Renewal for Recognition as a Complementary R

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Overview

Complementary Coversheet
Complementary Checklist

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Sheet 1: Complementary Coversheet

Application/Renewal for Recognition as a Complementary Reinsurer
PLEASE FILE THE FOLLOWING INFORMATION WITH THE U.S. DEPARTMENT OF TREASURY, BUREAU OF THE FISCAL SERVICE, SURETY BOND BRANCH, ON AN ANNUAL BASIS.
	Date:
	Company Name:
	RJIN Number:
	Domiciled Jurisdiction:
	State Recognized by:
	Mailing Address Line 1:
	Mailing Address Line 2:
	City
	State/Province
	Zipcode/Postcode
	Company Contact Name:
	Contact Number:
	Contact Email:
	Company President:
	Note: In addition to the above information, please provide the items outlined in Treasury's Annual Filing Checklist for Complementary Reinsurers as required by CFR 223.12(i)(3).

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Sheet 2: Complementary Checklist

Annual Filing Checklist
Complementary Reinsurer
	•	THE FOLLOWING CHECKLIST IS PROVIDED TO ASSIST YOUR COMPANY IN ELECTRONICALLY SUBMITTING A COMPLETE FILING TO THIS DEPARTMENT PER 31 CFR 223.12(i)
	•	PLEASE MARK EVERY ITEM ON THE CHECKLIST Y OR N/A
	•	IF N/A IS CHECKED, PLEASE INCLUDE AN EXPLANATION AS TO WHY THE DOCUMENT IS NOT INCLUDED
	•	THE SURETY BOND PROGRAM ONLY ACCEPTS ELECTRONIC SUBMISSIONS OF DOCUMENTS
	Check appropriate box:
			Initial Application (2 years of data)					Annual Renewal (1 year of data)
	Items to be Submitted								Submitted
									Yes		N/A
	1)	Proof of payment for application/renewal (pay online at https://fiscal.treasury.gov/surety-bonds/)
	2)	All information provided by the company to any U.S. state regulator for means of recognition in the most recently completed calendar year(s). This should include, but is not limited to the following as outlined in the NAIC Uniform Checklist (https://content.naic.org/sites/default/files/inline-files/Uniform%20Checklist%20for%20Reciprocal%20Jurisdiction%20Reinsurers%206-9-2020_0%20%281%29.pdf):
		a)	Status of Reciprocal Jurisdiction
		b)	Minimum Capital and Surplus
		c)	Minimum Solvency and Capital Ratio
		d)	Form RJ-1
		e)	Financial/Regulatory Filings
		f)	Prompt Payment of Claims
	Please detail additional items submitted below. Additionally, use the below space to provide comments as needed.