Department of Insurance s1

DEPARTMENT OF INSURANCE STATE OF NORTH CAROLINA

APPLICATION FOR LICENSE OR EXEMPTION AS A REINSURANCE INTERMEDIARY

GENERAL INSTRUCTIONS

1. COVER PAGE

The Applicant may request to be licensed as a Reinsurance Intermediary in North Carolina or to be exempted from licensing in North Carolina. The Applicant should mark the action being applied for on the cover page of the application.

2. PART A. TYPE OF LICENSE

The Applicant must choose at least one (1) category from each item. The Applicant may request to be licensed as a Reinsurance Intermediary Broker and Manager within one (1) application. For all other items of Part A, only one (1) category should be chosen.

An Applicant requesting to be licensed as a Reinsurance Intermediary Broker in Item 1 must complete Parts B, C, E, H and I of the application. An Applicant requesting to be licensed as a Reinsurance Intermediary Manager in Item 1 must complete Parts B, D, E, H and I of the application. A non-resident Applicant must also complete Part F of the application.

3. PART B. GENERAL INFORMATION

“Controlling person” is as defined in G.S. 58-9-2(a)(4).

4. PART D. MANAGER

The copy of each approved contract that must be submitted pursuant to Item 8 of this Part must be certified by an officer of the Applicant as being a true and complete copy of the contract approved by the reinsurer’s board of directors.

5. PART F. NONRESIDENT APPLICANT

If licensed, the Applicant shall thereafter notify the Commissioner of Insurance in writing of any change in the designated agent for service of process within five (5) business days after the change.

6. PART G. EXEMPTION

An Applicant requesting to be exempted from licensing in North Carolina as a Reinsurance Intermediary must complete Part B, Items 1, 2, 3, and 4; Part C, Items 4, 5, and 6 or Part D, Items 4, 5, 6, 7 and 8; Part G; Part H; and Part I.

FED .0526 1 3/04 An Applicant would qualify for exemption if it satisfies one of the following:

a. Acts as a Broker in North Carolina, maintains an office in North Carolina, and is an insurance agent or insurance broker licensed under Article 33 of the North Carolina Insurance Laws; or

b. Acts as a Broker in North Carolina, maintains an office in a state other than North Carolina, and is an insurance agent or insurance broker licensed under Article 33 of the North Carolina Insurance Laws or a Reinsurance Intermediary Broker licensed in a state having a law or rule substantially similar to Article 9 of the North Carolina Insurance Laws; or

c. Acts as a Manager for a reinsurer domiciled in North Carolina and is an insurance agent or insurance broker licensed under Article 33 of the North Carolina Insurance Laws; or

d. Acts as a Manager in North Carolina, maintains an office in North Carolina, and is an insurance agent or insurance broker licensed under Article 33 of the North Carolina Insurance Laws; or

e. Acts as a Manager in a state other than North Carolina, for an insurer licensed but not domiciled in North Carolina, and is an insurance agent or insurance broker licensed under Article 33 of the North Carolina Insurance laws or a Reinsurance Intermediary Manager licensed in a state having a law or rule substantially similar to Article 9 of the North Carolina Insurance Laws.

7. PART H. EXHIBITS

Exhibits filed with the application should be assigned an identifying number that indicates to which Part of the application it relates. For example, an organizational chart filed pursuant to Part B, Item 7 of the application could be numbered “Exhibit B.7.”

8. GENERAL

A Reinsurance Intermediary License will be valid for up to one year, expiring each year on December 31. The Department of Insurance will provide renewal application packages to licensed Reinsurance Intermediaries during the preceding month of October.

Exemptions from licensing in North Carolina as a Reinsurance Intermediary will be subject to periodic confirmation by the Department of Insurance.

The completed application should be filed to the attention of Ms. Nancy Wise, Department of Insurance, Company Services Group, 1203 Mail Service Center, Raleigh, NC 27699-1203.

FED .0526 2 3/04