Form L-NAV (v. 201404): Page 2 of 3
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SECTION IV: TRAINING REQUIREMENTS
Include a copy of your Navigator or CAC training certificate that shows successful completion of training.
SECTION V: ADDITIONAL INFORMATION
ALL applicants must complete this section. Carefully read and respond to each of the following questions. You should
provide a “YES” answer even if you believe an incident has been cleared from your record. Willful misrepresentation of any
fact required to be disclosed in any application or accompanying statement is a violation of law and a ground to deny your
application.
For the purposes of this application, "convicted" includes, but is not limited to, having been found guilty by judge or jury or pled
guilty or no contest to any felony charge. A "No" response is incorrect if applicant has had any conviction dismissed,
expunged, pardoned, appealed, set aside or reversed, or had its civil rights restored, had a plea withdrawn or has been given
probation, a suspended sentence or a fine, or successfully completed a diversion program.
A Has the applicant EVER had any professional, vocational, business license or certification refused,
denied, suspended, revoked or restricted, or a fine imposed by any public authority?
Yes No
B. Has the applicant EVER withdrawn an application for a license or certification to avoid its denial, or have
you EVER surrendered a license or certification to avoid disciplinary action?
Yes No
C. Has the applicant EVER been found guilty of, have you had a judgment made against you for, or have you admitted to, any
of the following:
1. A felony (of any kind)? ............................................................................................................................
2. Obtaining or attempting to obtain any type of license through misrepresentation or fraud? .................
3. Forging another's name to any document related to an insurance transaction? ...................................
4. Withholding, misappropriating, converting or stealing money or property? ...........................................
5. Committing an insurance unfair trade practice or fraud? .......................................................................
6. Using fraudulent, coercive or dishonest business practices including forgery with intent to defraud? ..
7. Conducting business in an incompetent, untrustworthy or financially irresponsible manner? ...............
8. Transacting, or helping someone else transact, insurance without the required license authority? ......
9. Intentionally misrepresenting the terms of an actual or proposed insurance contract or application for
insurance? ..............................................................................................................................................
10. Any misdemeanor involving fraud or dishonesty ...................................................................................
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
D. Is any case currently pending against the applicant in any jurisdiction accusing you of any issue listed in
Question C?: .................................................................................................................................................
Yes No
If you answered “YES” to any question in Section V, you must submit:
1. A SIGNED statement describing in detail all incidents including
a. names of all parties involved,
b. dates and locations,
c. the names and localities of any courts and/or administrative agencies involved,
d. the disposition of each matter,
e. whether the conviction, plea or finding was for a felony or open-ended charge;
AND
2. Certified copies of any and all indictments, complaints, plea agreements, orders of conviction, notices of hearing or trial,
sentencing orders, suspension/revocation orders and any other information which relates to each matter. If certified copies
are not available, you must provide as a part of this application a letter from the clerk of the pertinent court or the official
involved stating the records are not available and the reason.
NOTE: The Violent Crime Control and Law Enforcement Act of 1994 prohibits any person convicted of any criminal
felony involving dishonesty, breach of trust or a violation of the Act from engaging in the business of insurance
without the specific written consent of the appropriate state insurance regulatory official. 18 U.S.C. 1033. A person
who does not obtain the specific written consent may be subject to federal criminal prosecution. There is no
automatic waiver for an individual who may already possess a license. Further, the Act prohibits any person or entity
from willfully permitting a prohibited person, as described above, from engaging in the business of insurance and the
Act subjects such a person or entity to criminal sanctions.