Applicant’s Certification and Attestation
On behalf of the business entity or limited liability company, the undersigned owner, partner, officer or director of the
business entity, or member or manager of a limited liability company, hereby certifies, under penalty of perjury, that:
1. All of the information submitted in this application and attachments is true and complete and I am aware that
submitting false information or omitting pertinent or material information in connection with this application is
grounds for license or registration revocation and may subject me and the business entity or limited liability
company to civil or criminal penalties.
2. Unless provided otherwise by law or regulation of the jurisdiction , the business entity or limited liability
company hereby designates the Commissioner, Director or Superintendent of Insurance, or an appropriate
representative in each jurisdiction for which this application is made to be its agent for service of process
regarding all insurance matters in the respective jurisdiction and agree that service upon the Commissioner or
Director of that jurisdiction is of the same legal force and validity as personal service upon the business entity.
3. The business entity or limited liability company grants permission to the Commissioner or Director of Insurance
in each jurisdiction for which this application is made to verify any information supplied with any federal, state
or local government agency, current or former employer or insurance company.
4. Every owner, partner, officer or director of the business entity, or member or manager of a limited liability
company, either a) does not have a current child-support obligation, or b) has a child-support obligation and is
currently in compliance with that obligation.
5. I authorize the jurisdictions to which this application is made to give any information they may have concerning
me, as permitted by law, to any federal, state or municipal agency, or any other organization and I release the
jurisdictions and any person acting on their behalf from any and all liability of whatever nature by reason of
furnishing such information.
6. I acknowledge that I understand and comply with the insurance laws and regulations of the jurisdictions to
which I am applying for licensure/registration.
7. For Non-Resident License Applications, I certify that I am licensed and in good standing in my home
state/resident state for the lines of authority requested from the non-resident state.
8. I hereby certify that upon request, I will furnish the jurisdiction(s) to which I am applying, certified copies of any
documents attached to this application or requested by the jurisdiction(s).
9. I certify that the Designated Responsible Licensed Producer(s) named on this application understands that
he/she is responsible for the business entity’s compliance with the insurance laws, rules and regulation of the
Must be signed by an officer, director, or partner of the business
entity, or member or manager of a limited liability company:
Typed or Printed Name
City State Zip
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