831(b) Plan Application
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831(b) Plan ARC Application
Record Type ID
Year Submitted
Plan Name Choice
First Choice
Second Choice
How did you hear about us?
Select To See
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:
Is identical
to an existing company
;
Contains the
words
“Chamber of Commerce";
Contains
the
word
(s
) “Assurance:, “Bank
”
, “Building
Society”
,
“Commonwealth”,
“
Co-Operative Society
”
,
“
Fidelity
”
,
“
Friendly Society
”
,
“
Guarantee
”
,
“Indemnity
”
,
“Insurance
”
, “Trust
”
, “Trustee", or
“Underwriter”
;
Includes
at
it
s
end, “Limited
Life
Company”
or the
abbreviation "
LLC
”
as well
as
"
Limited
”
or the abbreviation
“
Ltd
.
”
; and
/
or
Contains any words offensive or in reference
to
the Modoc Tribe,
Tribal Council,
Chief or Nati
ve A
merican 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.
Company Record Type
831(b) Plan ARC Application (Cont.)
President
First Name
Last Name
Social Security Number
Please enter numbers only (without dashes)
Are you a Shareholder?
Please select...
Yes
No
Number of Shares
Total of 5000 shares available between all Officers
Email
Phone
Mailing Street
City
State/Province
Country
Mailing Zip/Postal Code
Yes
No
Is the President the Primary Point of Contact?
Please Upload Photo ID of President
Title
Please select...
Vice President
Board Member
Shareholder
Treasurer
President
Secretary
First Name
Last Name
Social Security Number
Please enter numbers only (without dashes)
Are you a Shareholder?
Please select...
Yes
No
Number of Shares
Total of 5000 shares available between all Officers
Email
Phone
Mailing Street
City
State/Province
Country
Mailing Zip/Postal Code
Yes
No
Is the Secretary the Primary Point of Contact?
Please Upload Photo ID of Secretary
Title
Please select...
Vice President
Board Member
Shareholder
Treasurer
President
Secretary
831(b) Plan ARC Application (Cont.)
Do you have additional Shareholders/
Board Members
?
Please select...
Yes
No
Shareholder/Board Member
First Name
Last Name
Title
Please select...
Vice President
Board Member
Shareholder
Treasurer
President
Secretary
Social Security Number
Please enter numbers only (without dashes)
Are you a Shareholder?
Please select...
Yes
No
Number of Shares
Total of 5000 shares available between all Officers
Email
Phone
Mailing Street
City
State/Province
Country
Mailing Zip/Postal Code
Please Upload Photo ID of Shareholder/Board Member
Operating Company Fact Finder
Entity Information
Legal Name of Business
Abbreviation
DBA
Physical Street Address
City
State
Zip
Web Address
Year Organized
EIN
Number of Employees
Please select...
C-Corporation
S-Corporation
Limited Liability Company
Limited Partnership
Partnership
Sole Proprietorship
Type of Entity
State of Incorporation
Please select...
Agriculture
Apparel
Banking
Biotechnology
Chemicals
Communications
Construction
Consulting
Education
Electronics
Energy
Engineering
Entertainment
Environmental
Finance
Food & Beverage
Government
Healthcare
Hospitality
Insurance
Machinery
Manufacturing
Media
Not For Profit
Other
Recreation
Retail
Shipping
Technology
Telecommunications
Transportation
Utilities
Industry
Specific
Gross Earnings (Last 4 Years)
Current Year Projected
Previous Year
Two Years Prior
Three Years Prior
Accounting
Is your company on accrual accounting?
Please select...
Yes
No
When does your fiscal year end?
mm/dd
First Choice (From Plan Arc Form )
Second Choice (From Plan Arc Form)
Presidents SS# (From Plan Arc Form )
Record Type ID (Operating/Producing ID)
Business Owner(s)
First Name
Last Name
Ownership Percent
Email
831(b) Plan Risk Co-Ops
Safe Harbor Plan Options
Co-ops / Plans
Low Priority
Medium Priority
High Priority
N/A
Professional Liability
Dispute Resolution
Political Risk
Recall
Audit Assurance
Employer Liability Interruption
Third Party Business Interruption
Key Employee Loss - Critical Illness
Supply Chain Interruption
Contingent Business Interruption
Food Borne Illness
Brand Protection
Data Breach Liability + Loss of Income
Representations & Warranties
Credit Default
Directors & Officers
Select to participate
Dental Protection Plan
Tenant Assurance
Storage Assurance
Custom Warranty
Deductible Reimbursement
Medical Allied Reinsurance Company
Contract Default Liability
Tax Audit Assurance
Tenant Rent Protection
Click here for full list of policies with descriptions.
Yes
Do you require fact finders for additional operating companies you wish to include?
Terms & Service Agreement
By submitting this application you are acknowledging that you have reviewed the information provided above and ensure its accuracy and reliability.
Full Name
Date MM/DD/YYYY
Yes
I have read and agree to the Terms of Service
Please select "Submit" one time - the form may take a few seconds to process. Thank you!
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