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ALABAMA DEPARTMENT OF INSURANCE (Alabama Department of Insurance)

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ALABAMA DEPARTMENT OF INSURANCE
201 MONROE STREET, SUITE 1700
POST OFFICE BOX 303351
MONTGOMERY, ALABAMA 36130-3351
TELEPHONE: (334) 269-3550 FACSIMILE: (334) 241-4192
INTERNET: www.aldoi.gov
VEHICLE PROTECTION PRODUCT WARRANTOR REGISTRATION APPLICATION
Zip CodeState
TYPE OF APPLICATION:
NEW RENEWAL OF REGISTRATION NUMBER
City
Address
MAILING ADDRESS
Zip CodeStateCity
Address
PHYSICAL ADDRESS
FEIN NUMBER
FAX NUMBER
PHONE NUMBER
ASSUMED NAME(S) OR DBA NAME(S)
NAME OF BUSINESS TO BE REGISTERED
TYPE OF OWNERSHIP
CORPORATION
PARTNERSHIP
LIMITED LIABILITY COMPANY
INDIVIDUAL
TYPES OF PRODUCTS SOLD
IGNITION INTERRUPT
AUTO ALARM SYSTEMS
WINDOW IDENTIFICATION SYSTEMS
OTHER
AGENT FOR SERVICE OF PROCESS
FORM: AL-VPP-APP 01/2007
SSN
Name
Address
City State Zip Code Phone Number
OFFICERS
President
Secretary
Treasurer
Vice President
Vice President
Vice President
Page 1 of 4
Print Form
01/2007FORM: AL-VPP-APP
I CERTIFY THAT I HAVE READ AND WILL ABIDE BY THE ALABAMA VEHICLE PROTECTION PRODUCT ACT, ALABAMA ACT
2006-600. UPON REQUEST OF THE DEPARTMENT, I AGREE TO MAKE AVAILABLE ALL RECORDS MAINTAINED PURSUANT TO
THE REQUIREMENTS OF SAID ACT AND ANY SUBSEQUENT ALABAMA DEPARTMENT OF INSURANCE REGULATIONS ENACTED
PURSUANT THERETO TO THE COMMISSIONER OR HIS/HER DULY APPOINTED DESIGNEE.
WITH KNOWLEDGE OF THE PENALTIES FOR FALSE STATEMENTS, I CERTIFY THAT ALL INFORMATION SUBMITTED WITH THIS
APPLICATION AND ALL ATTACHED DOCUMENTATION IS TRUE AND CORRECT.
PRINTED NAME DATE
TITLEAPPLICANT SIGNATURE
OFFICERS- Continued
DIRECTORS
Page 2 of 4
APPLICATION CHECKLIST
IF THE $50 MILLION NET WORTH OPTION IS USED, FILE AN AUDITOR'S UNQUALIFIED OPINION ALONG WITH ONE
OF THE FOLLOWING:
1. AUDITED FINANCIAL STATEMENT SHOWING A NET WORTH OF AT LEAST $50 MILLION AT THE END OF THE
APPLICANT'S MOST RECENT FISCAL YEAR-END.
2. AUDITED FINANCIAL STATEMENT SHOWING A NET WORTH OF AT LEAST $50 MILLION AT THE END OF THE
APPLICANT'S PARENT CORPORATION'S MOST RECENT FISCAL YEAR-END. NOTE: IF THE PARENT
CORPORATION'S FORM 10-K, 20-F OR AUDITED FINANCIAL STATEMENTS ARE USED THE PARENT COMPANY
MUST HAVE ON FILE WITH THE DEPARTMENT A GUARANTEE RELATING TO WARRANTIES ISSUED BY THE
WARRANTOR IN THE STATE OF ALABAMA. A BOARD RESOLUTION MUST BE ATTACHED TO THE
APPLICATION ACKNOWLEDGING THE GUARANTEE AND ITS CONTINUED EXISTENCE FOR THE YEAR IN
WHICH THE APPLICATION PERTAINS.
CERTIFICATE OF GOOD STANDING STATUS
FINANCIAL SECURITY DOCUMENTS
FEES
A CERTIFICATE OF GOOD STANDING STATUS MUST BE SUBMITTED FOR A CORPORATION OR LIMITED LIABILITY COMPANY
THAT PROVIDES VEHICLE PROTECTION PRODUCT WARRANTEES IN ALABAMA. THIS CERTIFICATE MAY BE OBTAINED FROM
THE ALABAMA SECRETARY OF STATE'S OFFICE OR REQUESTED VIA THE INTERNET AT www.sos.state.al.us.
THE FINANCIAL SECURITY REQUIREMENTS DESCRIBED IN SECTION 5 OF THE ACT CAN BE SATISFIED BY HAVING A
REIMBURSEMENT INSURANCE POLICY OR BY ESTABLISHING A MINIMUM NET WORTH OF $50 MILLION. PLEASE INDICATE
WHICH OPTION THE APPLICANT HAS ELECTED TO USE IN SATISFACTION OF THE FINANCIAL SECURITY REQURIEMENTS.
REIMBURSMENT INSURANCE POLICY
$50 MILLION NET WORTH
IF THE REIMBURSEMENT INSURANCE POLICY OPTION IS USED THE APPLICANT MUST ATTACH A CERTIFICATE OF
INSURANCE ISSUED BY AN INSURER AUTHORIZED TO DO BUSINESS IN THE STATE OF ALABAMA.
A CHECK OR MONEY ORDER IN THE AMOUNT OF $250 MUST BE ATTACHED TO THE APPLICATION FOR THE TOTAL
AMOUNT DUE PAYABLE TO THE ALABAMA COMMISSIONER OF INSURANCE .
CORPORATE DOCUMENTS
IF NEW CORPORATE APPLICATION ATTACH COPY OF ARTICLES OF INCORPORATION, FORMATION, ASSOCIATION OR
PARTNERSHIP AGREEMENT.
CONTRACTS
IF NEW APPLICATION ATTACH A SPECIMEN OF ALL WARRANTY CONTRACTS TO BE USED IN THE STATE OF ALABAMA. IF
RENEWAL, ATTACH SPECIMEN OF ANY CONTRACT REVISIONS OR NEW CONTRACTS TO BE USED IN ALABAMA IN THE YEAR
IMMEDIATELY FOLLOWING RENEWAL.
EXAMINATION AGREEMENT
A PROPERLY COMPLETED AGREEMENT TO SUBMIT TO AN EXAMINATION MUST BE ATTACHED TO ALL NEW APPLICATIONS.
NEW APPLICATIONS RETURNED WITHOUT AN AGREEMENT WILL BE CONSIDERED INCOMPLETE .
THE APPLICATION, ATTACHMENTS AND FEE SHOULD BE MAILED TO THE ALABAMA DEPARTMENT OF INSURANCE AT THE
FOLLOWING ADDRESS.
PO BOX 303350
MONTGOMERY, AL 36130
TO BECOME A REGISTERED VEHICLE PROTECTION PRODUCT WARRANTOR OR RENEW AN EXISTING REGISTRATION, THE FOLLOWING MUST
BE ATTACHED TO FORM AL-VPP-APP IN SATISFACTION OF THE REQURIEMENTS SET FORTH IN THE ALABAMA VEHICLE PROTECTION
PRODUCT ACT, ALABAMA ACT 2006-600. PLEASE INDICATE BELOW THOSE ITEMS THAT HAVE BEEN ATTCHED BY CHECKING THE
APPROPRIATE BOX.
01/2007FORM: AL-VPP-APP
Page 3 of 4
BIOGRAPHICAL AFFIDAVITS
New applicants must submit an affidavit for those individuals identified in the affidavit instructions. Renewal applications
should contain affidavits for those individuals identified in the affdavit instructions that did not occupy the indicated
position as of the previous application submission.
AGREEMENT TO SUBMIT TO AN EXAMINATION
IN WITNESS WHEREOF, the above name company has caused its name to be subscribed hereto by its President,
or other proper officer, and attested by its Secretary, and has hereunto caused its corporate seal to be affixed.
THE STATE OF
COUNTY OF
THIS INSTRUMENT WITNESSETH: That for and in consideration of the issuance of a license to transact business
in the State of Alabama, application for which has been filed with the Commissioner of Insurance of Alabama,
the below identified company does hereby agree that the Commissioner of Insurance of the State of Alabama,
may, whenever he deems it necessary, make an examination into the condition of its affairs; that said
examination may be conducted by said Commissioner, his deputy, or such other qualified person or persons as
he may designate or appoint for such purpose; that such of its books, papers and securities, as may be required,
will be submitted to said examiner or examiners; that said examiner or examiners shall have the right and
power to examine its officers under oath touching its business and financial condition; and that all the proper
charges incurred in such examination, including the expenses of the Commissioner of Insurance, or his deputy,
and the expenses and compensations of his authorized examiner or examiners, will be paid by said company or
association, when approved by said Commissioner.
(SEAL)
Signature
By
Its President
Attested By
Signature
Company Name
Address
City State Zip Code
Country
This day of
,
.
Its Secretary
01/2007FORM: AL-VPP-APP
Page 4 of 4
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ALABAMA DEPARTMENT OF INSURANCE (Alabama Department of Insurance)

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Completed 20 July 2020

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