831(b) Plan ARC Application

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Record Type ID

Year Submitted

Plan Name Choice

First Choice:

Reinsurance Company, Inc.

Second Choice:

Reinsurance Company, Inc.

How did you hear about us:

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See Naming Parameters

Reinsurance Company Name Choices

Submit at least two name choices for your reinsurance company.
Choices should be as unique as possible.
No company shall be registered by a name which:
1) Is identical to an existing company;
2) Contains the words “Chamber of Commerce";
3) Contains the word(s) “Assurance:, “Bank”, “Building Society”,
“Commonwealth”, “Co-Operative Society”, “Fidelity”, “Friendly Society”,
“Guarantee”, “Indemnity”, “Insurance”, “Trust”, “Trustee", or
“Underwriter”;
4) Includes at its end, “Limited Life Company” or the abbreviation "LLC”
as well as "Limited” or the abbreviation “Ltd.”; and/or
5) Contains any words offensive or in reference to the Modoc Tribe,
Tribal Council, Chief or Native American Nation

An 831(b) Plan has tax implications in a number of areas including (but not limited to): estate, gift and income taxes. Clients should always be advised to rely on their legal and tax advisors to help them navigate through their various tax issues. SRA 831(b) Admin and its representatives do not give tax or legal advice. Please consult with your attorney, accountant, or tax advisor for additional information.

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President

First Name

Last Name

Social Security Number

Are you a Shareholder?

Number of shares

Total of 5000 max shares

Phone

Mailing Street

City

State/Province

Country

Mailing Zip/Postal Code

	Yes	No
Is President the Primary Point of Contact?

Please Upload Photo ID of President

Title

Secretary

First Name

Last Name

Social Security Number

Are you a Shareholder?

Number of shares

Total of 5000 max shares

Phone

Mailing Street

City

State/Province

Country

Mailing Zip/Postal Code

Is Secretary the Primary Point of Contact?

YesNo

Please Upload Photo ID of Secretary

Title

Do you have additional board members/ shareholders?

Shareholder/Board Member

First Name

Last Name

Title

Phone

Social Security Number

Number of Shares

Total of 5000 max shares

Mailing Street

City

State/Province

Country

Mailing Zip/Postal Code

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