831(b) Plan Application

For questions on this application, please reach out to Haley Hunt:

Email: haley@831b.com

Phone: (208)424-2249 ext. 1012

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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 its 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 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.

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?

Number of Shares

Total of 5000 shares available between all Officers

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

Secretary

First Name

Last Name

Social Security Number

Please enter numbers only (without dashes)

Are you a Shareholder?

Number of Shares

Total of 5000 shares available between all Officers

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

831(b) Plan ARC Application (Cont.)

Do you have additional Shareholders/Board Members?

Shareholder/Board Member

First Name

Last Name

Title

Social Security Number

Please enter numbers only (without dashes)

Are you a Shareholder?

Number of Shares

Total of 5000 shares available between all Officers

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

Type of Entity

State of Incorporation

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?

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

	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
Warranty Reimbursement
Deductible Reimbursement
Medical Allied Reinsurance Company
Subcontractor Default Liability
Tax Audit Assurance
Tenant Rent Protection
Livestock Death Loss

Click here for full list of policies with descriptions.

	Yes	No
Do you require fact finders for additional operating companies you wish to include?

Do you intend to contribute premium payments from any of these additional operating companies?

Yes, at least one additional entity will contribute premium paymentsNo, they will be additionally insured

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

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