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APPLICANT MUST PERSONALLY COMPLETE AND SIGN THIS APPLICATION (Department of Technology and Information)

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BROWSE DEPARTMENT OF TECHNOLOGY AND INFORMATION (DE) FORMS

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APPLICANT MUST PERSONALLY COMPLETE AND SIGN THIS APPLICATION
(PLEASE PRINT OR TYPE)
REQUEST FOR BUSINESS ENTITY INSURANCE LICENSE
Application must be completed and signed by the proprietor, a partner or an officer of the firm
PART 1 CORPORATION, PARTNERSHIP, ASSOCIATION, ETC.
NAME _______________________________________________________________________________________
F.E.I.N. ______________________________________________________________________________________
ADDRESS _________________________________________________ SUITE OR BOX NO._________________
CITY ______________________ STATE ___________ ZIP ______________PHONE________________________
BUSINESS EMAIL ADDRESS ______________________________WEBSITE ADDRESS_____________________
ADDRESS __________________________________________________ SUITE OR BOX NO. ________________
CITY _____________________STATE _______________ ZIP ______________PHONE______________________
ALTERNATE EMAIL ADDRESS ___________________________________________________________________
PART 2 DESIGNATED RESPONSIBLE LICENSED PRODUCER
Identify at least on Designated Responsible Licensed Producer.
Name: _________________________________________________________ SSN: _______________________________
Name: _________________________________________________________ SSN: ________________________________
Name: _________________________________________________________ SSN: ________________________________
Name: _________________________________________________________ SSN: _________________________________
BUSINESS ADDRESS INFORMATION
MAILING ADDRESS INFORMATION
2B
Revised 07/17
PART 3 TYPE OF LICENSE REQUESTED
PRODUCER $100 APPRAISER $100 LIMITED LINES PRODUCER
$100
ADJUSTER $100 SURPLUS LINES BROKER $250 BAIL PRODUCER
$200
PUBLIC ADJUSTER $100 FRATERNAL PRODUCER $100 17B TRAVEL
$1000
PART 4 STRUCTURE OF COMPANY
Corporation
Partnership
Sole Proprietorship
Limited Liability Company
Limited Liability Partnership
A. WHAT TYPE OF ORGANIZATION? _____________________________________________________
B. DATE OF ORGANIZATION____________________________________________________________
C. STATE OF DOMICILE ________________________________________________________________
PART 5 PRINCIPAL OFFICERS
NAME ________________________________ SSN ________________________ POSITION ____________________
NAME ________________________________ SSN ________________________ POSITION ____________________
NAME ________________________________ SSN ________________________ POSITION ____________________
NAME ________________________________ SSN ________________________ POSTION _____________________
Please read the following very carefully and answer every question. All written
statements submitted by the Applicant must include an original signature.
1a. Has the business entity or any owner, partner, officer or director of the business entity, or member or manager of
a limited liability company, ever been convicted of a misdemeanor, had a judgment withheld or deferred or is the
business entity or any owner, partner, officer or director of the business entity, or member or manager currently
charged with, committing a misdemeanor?
Yes ___ No___
You may exclude the following misdemeanor convictions or pending misdemeanor charges: traffic citations,
driving under the influence (DUI) or driving while intoxicated (DWI), driving without a license, reckless driving,
or driving with a suspended or revoked license. You may also exclude juvenile adjudications (offenses where you
were adjudicated delinquent in juvenile court.)
1b. Has the business entity or any owner, partner, officer or director of the business entity, or member or manager of
a limited liability company ever been convicted of a felony, had judgment withheld or deferred, or is the business
entity or any owner, partner, officer or director of the business entity or member or manager of a limited liability
company currently charged with committing a felony?
Yes ___ No___
You may exclude juvenile adjudications (offenses where you were adjudicated delinquent in a juvenile court.)
If you have a felony conviction involving dishonesty or breach of trust, have you applied for written consent to
engage in the business of insurance in your home state as required by 18 USC 1033?
N/A___ Yes____ No____
If so, was consent granted? (Attach copy of 1033 consent approved by home state.)
N/A___ Yes____ No____
1c. Has the business entity or any owner, partner, officer or director of the business entity or member or manager of a
limited liability company, ever been convicted of a military offense, had a judgment withheld or deferred, or is
the business entity or any owner, partner, officer or director of the business entity or member or manager of a
limited liability company, currently charged with committing a military offense?
Yes ___ No___
NOTE: For Questions 1a, 1b, and 1c “Convicted” includes, but is not limited to, having been found guilty by
verdict of a judge or jury, having entered a plea of guilty or nolo contendere or no contest, or having been given
probation, a suspended sentence or a fine.
If you answer yes to any of these questions, you must attach to this application:
a) a written statement identifying all parties involved (including their percentage of ownership, if any) and
explaining the circumstances of each incident,
b) a copy of the charging document,
c) a copy of the official document which demonstrates the resolution of the charges or any final judgment.
2. Has the business entity or any owner, partner, officer or director of the business entity, or manager or member of
a limited liability company, ever been named or involved as a party in an administrative proceeding, including a
FINRA sanction or arbitration proceeding regarding any professional or occupational license, or registration?
Yes ___ No___
“Involved” means having a license censured, suspended, revoked, canceled, terminated; or, being assessed a fine,
a cease and desist order, a prohibition order, a compliance order, placed on probation, sanctioned or surrendering
a license to resolve an administrative action. “Involved” also means being named as a party to an administrative
or arbitration proceeding, which is related to a professional or occupational license or registration. “Involved”
also means having a license application denied or the act of withdrawing an application to avoid a denial. You
may EXCLUDE terminations due solely to noncompliance with continuing education requirements or failure to
pay a renewal fee.
If you answer yes to any of these questions, you must attach to this application:
a.) a written statement identifying all parties involved (including their percentage of ownership, if any) and
explaining the circumstances of each incident,
b) a copy of the charging document,
c) a copy of the official document which demonstrates the resolution of the charges or any final judgment.
3. Has any demand been made or judgment rendered against the business entity or any owner, partner, officer or
director of the business entity, or member or manager of a limited liability company, for overdue monies by an
insurer, insured or producer, or have you ever been subject to a bankruptcy proceeding? Do not include personal
bankruptcies, unless they involve funds held on behalf of others.
N/A___Yes ___ No___
If you answer yes, submit a statement summarizing the details of the indebtedness and arrangements for
repayment.
4. Has the business entity or any owner, partner, officer or director of the business entity, or member or manager of
a limited liability company, ever been notified by any jurisdiction to which you are applying of any delinquent
tax obligation that is not the subject of a repayment agreement?
Yes ___ No___
If you answer yes, identify the jurisdiction(s): _______________________________________
5. Is the business entity or any owner, partner, officer or director of the business entity, or member or manager of a
limited liability company, a party to, or ever been found liable in any lawsuit or arbitration proceeding involving
allegations of fraud, misappropriation or conversion of funds, misrepresentation or breach of fiduciary duty?
Yes ___ No___
If you answer yes, you must attach to this application:
a) a written statement summarizing the details of each incident,
b) a copy of the Petition, Complaint or other document that commenced the lawsuit arbitrations, or
mediation proceedings and
c) a copy of the official documents which demonstrates the resolution of the charges or any final
judgment.
6. Has the business entity or any owner, partner, officer or director of the business entity, or member or manager of
a limited liability company ever had an insurance agency contract or any other business relationship with an
insurance company terminated for any alleged misconduct?
Yes ___ No___
If you answer yes, you must attach to this application:
a) a written statement summarizing the details of each incident and explaining why you feel
this incident should not prevent you from receiving an insurance license, and
b) copies of all relevant documents.
7. In response to a “yes” answer to one or more of the Background Questions for this application, are you
submitting document(s) to the NAIC/NIPR Attachments Warehouse?
N/A___Yes ___ No___
If you answer yes:
Will you be associating (linking) previously filed documents from the NAIC/NIPR Attachments Warehouse to
this application?
Yes ___ No___
Note: If you have previously submitted documents to the Attachments Warehouse that are intended to be filed
with this application, you must go to the Attachments Warehouse and associate (link) the supporting
document(s) to this application based upon the particular background question number you have answered yes
to on this application. You will receive information in a follow-up page at the end of the application process,
providing a link to the Attachment Warehouse instructions.
Attachments
The following attachments must accompany the application otherwise the application may be returned unprocessed or
considered deficient.
1. For Non-Resident License Applications and unless otherwise noted in the State Matrix of Business Rules, a state
will rely on an electronic verification of an Applicant’s resident license through the NAIC’s State Producer
Database in lieu of requiring an original Letter of Certification from the resident state.
2. Any jurisdiction specific attachments listed in the State Matrix of Business Rules (www.nipr.com).
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
State.
Must be signed by an officer, director, or partner of the business
entity, or member or manager of a limited liability company:
______________________________________
Month/Day/Year
_____________________________________
Signature
________________________________________
Typed or Printed Name
________________________________________
Title
________________________________________
Address
________________________________________
City State Zip
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APPLICANT MUST PERSONALLY COMPLETE AND SIGN THIS APPLICATION (Department of Technology and Information)

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Completed 20 July 2020

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