Fillable Background Information Change Disclosure Form (California)

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Background Information Change Disclosure Form (California)

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The Background Information Change Disclosure Form (California) form is 4 pages long and contains:

  • 1 signature
  • 25 check-boxes
  • 30 other fields

Country of origin: US
File type: PDF

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State of California Department of Insurance
Background Information Change Disclosure Form
Licensing Background Bureau
LIC #2557B (Rev 11/10)
Background Information Change Disclosure Form
(Per CIC 1729.2)
This form has been developed to assist you in making the required background change reporting
requirements under the provisions of section 1729.2 of the California Insurance Code. Failure to
comply with CIC 1729.2 may result in denial or revocation of your license and/or denial of your
application for a license. Refer to the attached Instructions (LIC 2557-A) for additional information.
Providing your social security number is mandatory.
Section A: Check the box(es) that applies to you:
Individual Licensee
Business Entity licensee
Endorsee under Business Entity License
Business Entity Reporting Background Change of Unlicensed Officer, Director, Partner, member
or 10% or more greater shareholder, or Controlling Person (as defined in CIC 1668.5[b]).
New License Applicant, (check only one):
Business Entity Individual Licensee Endorsee to Be Named Under a Business Entity.
Unlicensed officer, director, partner, member, or controlling person under a business entity license
or application.
California Resident Non Resident (If non resident, list state of residence: )
Print name:
First Middle Last Social Security #
Other name(s):__________________________________________________________________
(List any other names by which you have been known (Including maiden names, AKA’s or aliases)
Address: Phone: ( )
Street City State
Business name and address of employer or business entity:
License number: Application pending? Yes No
*Position or Title:
*(Complete only if you are an endorsee of an organization)
Page 1 of 4
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State of California Department of Insurance
Background Information Change Disclosure Form
Licensing Background Bureau
LIC #2557B (Rev 11/10)
Section B: Please check below the background changes you are reporting and disclosing:
1. Have you* been convicted of a crime? ** Yes No
2. Have you* been charged with a felony? Yes No
3. Have you* been charged by an administrative agency with a violation involving a professional
or occupational license? Yes No
4. Have you* been discharged or attempted to discharge in bankruptcy a debt involving premium
or return premium? Yes No
5. Have you made any admission, or had a judicial finding or determination of fraud, misappropriation
or conversion of funds, misrepresentation or breach of fiduciary duty? Yes No
* If this Background Change Disclosure is being submitted by an organization, “you” means the
organization and any officer, director, partner, member, endorsee, 10% or greater shareholder, and
controlling person (as defined in Insurance Code Section 1668.5[b]). The changes subject to this
requirement include changes pertaining to any unlicensed officer, director, partner, member, or
controlling person, or any other natural person named under the business entity license or
application.
** “Crime” includes a felony, a misdemeanor or a military offense. “Convicted” includes, but is not
limited to, having been found guilty by a verdict of a judge or jury, having entered a plea of guilty or
nolo contendere, having had any charge expunged, dismissed or plea withdrawn pursuant to Penal
Code 1203.4, or having been given probation, a suspended sentence or a fine. You may exclude
traffic citations and juvenile offenses tried in juvenile court. You must disclose misdemeanor and
felony vehicle code convictions, including any driving under the influence (DUI) convictions.
Important Notice: If you checked box 1, 2, 3, 4, or 5 attach a detailed statement signed by the
person most involved with the event explaining what occurred. If you were convicted of a crime,
attach copies, Certified by the Court, of the Criminal Complaint and Minute Order showing the final
plea, judgment and sentence. If criminal, civil or administrative charges were filed, attach certified
copies of the court records and/or official documents which demonstrate the resolution of the charges
or any final judgement. If a Bankruptcy filing is being reported related to insurance premiums or trust
funds, provide certified copies of the final bankruptcy discharge document from the court which
demonstrates the final resolution.
Page 2 of 4
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State of California Department of Insurance
Background Information Change Disclosure Form
Licensing Background Bureau
LIC #2557B (Rev 11/10)
Section C: Important information for licensees who are endorsees under Business Entity
licenses or Applications: If the background change reported by you involves you and you are an
endorsee on a business entity license, then you must also provide this background change notice to
any officer, director, or partner listed on that business entity license within 30 days of learning of the
background change (CIC 1729.2 [b]).
If you are an endorsee, please check this box (C) to certify that you have notified the business
entity license holder for which you are named as an endorsee and provide the date of the
notification.
Box C I certify that I have also notified the business entity license holder for which I am named as
an endorsee on of the background changes I have noted in box(s) 1, 2, 3, 4
or 5 above. (date)
Name of Person Reported to:
Name and Address of Business Entity:
Business Entity License #:
Important information for business entity licensees or applicants: If the background change
matter being reported by you involves any unlicensed officer, director, partner, member, endorsee,
10% or greater shareholder, or any controlling person (as defined in Insurance Code Section
1668.5(b)) of the organization, then an officer, director, partner, member, or controlling person, (as
defined in 1668.5(b)) must also report the background change involving the unlicensed person.
Section D: Please check this box (D) below only if you are notifying the Commissioner of a
background change on behalf of a business entity license involving an unlicensed officer, director,
partner, endorsee, 10% or greater shareholder or any controlling person (as defined insurance code
section 1668.5[b]).
Box D I certify that I am an officer, director or controlling person of an organization and I am
notifying the Commissioner that an unlicensed officer director, partner, member, endorsee, 10% or
greater shareholder, or any other controlling person as defined in Insurance Code Section 1668.5 has
had a change in background information as per CIC 1729.2). I have noted the background changes
being reported in box 1, 2. 3, 4, or 5 above
.
Provide Name of Unlicensed Officer, Director, Partner, Member, Endorsee, 10% or Greater
Shareholder, or any other Controlling person as defined in CIC 1668.5.
Name of unlicensed person:
Name and address of business entity:
Business Entity License #: Telephone: ( )
Page 3 of 4
State of California Department of Insurance
Background Information Change Disclosure Form
Licensing Background Bureau
LIC #2557B (Rev 11/10)
Section E: Applicant/Licensees Certification:
I certify or declare under penalty of perjury under the laws of the State of California that I have read
the above disclosures and that was statement made therein is full, true and correct. I understand that
any changes in background information (per CIC 1729.2) must be filed within 30 days or my license
can be subjected to disciplinary action. I certify that other than the disclosures being made above, I
have no other unreported changes in background information to report as required under CIC 1729.2.
Signature►
Date: City: State:
Print Name:
Applicant’s Title (If Organization/Business Entity):
Name of Organization (if Organization/Business Entity):
Email address:
Page 4 of 4
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Background Information Change Disclosure Form (California)

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Completed 15 April 2021

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