Fillable Business Entity Application for Insurance License (California)

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Business Entity Application for Insurance License (California)

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The Business Entity Application for Insurance License (California) form is 5 pages long and contains:

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  • 26 check-boxes
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State of California –
Department of Insurance
Business Entity Application for Insurance License
LIC 441-11 Rev 03/2019
1. Business Entity Types (Check one only)
Corporation Limited Liability Partnership/Limited Partnership
General Partnership Nonprofit Corporation
Limited Liability Company Unincorporated Association
Department Use Only
License_____________
2. License Type
Life-Only Agent (LO)
Variable Contract Authority (VC)
Accident and Health Agent (AH)
Property Broker-Agent (PR)
Casualty Broker-Agent (CA)
Personal Lines Broker-Agent (PL)
Limited Line Automobile Insurance Agent (AU)
Credit Insurance Agent (CI)
Motor Club Agent (MC)
Self-Service Storage Agent (SS)
Portable Electronics Insurance Agent (PE)
Surplus Line Broker (SL)
Special Lines’ Surplus Line Broker (SP)
Life & Disability Analyst (LA)
Cargo Shipper’s Agent (CS)
Vehicle Service Contract Provider VS
Rental Car Agent (RC)
Travel Insurance Agent (TA)
3. Business Entity Name
4. Federal Employer Identification Number
__ __ __ __ __ __ __ __ __
5. Name Approval Confirmation #
6. State of Incorporation
7. Business address (PO Box not acceptable)
8. Business phone number
( )
9. Business fax number
( )
11. Mailing Address (PO Box is acceptable)
12. Fictitious names
a. Does the business entity intend to use a fictitious (DBA) name? Yes No
If yes, list such name: (This name must be approved by the Department prior to use.)
________________________________________________
b. Is the business entity now or has it ever used any name other than shown? Yes No
If yes, list names, dates and reason(s) used:
_________________________________________________________________________________
13. Business Entity Information:
Is this business entity engaged in any business or activity other than insurance? Yes No
If yes, answer the following:
a. What is the nature of this other business or activity? ________________________________________________________
b. What percentage of the business entity’s net income will be derived from this other business or activity? _______________
Important: Business entity applicants engaged in business other than insurance are cautioned to review the laws governing such other
business to ensure that the transacting of insurance is not incompatible under such laws.
14. Is the business entity an insurer? Yes No
15. Does the Business Entity hold an insurance license and is the Business Entity adding a line of authority? Yes No
Or has the Business Entity ever held an insurnace license as a resident in any state, including the state of California? Yes No
If yes, complete the following: (attach a separate sheet if needed)
Type of License and License Number State or Province Date License Held Is License In Force?
• •
16. Life-Only Agent License Applicants only:
Does the business entity intend to act as a Variable Contract Agent? Yes No
Any business entity intending to act as a Variable Contract Agent must have at least one Designated/Responsible Licensed Producer
authorized as a Variable Contract Agent.
17. Designated/Responsible Licensed Producer (s)
Identify all Designated/Responsible Licensed Producers* (Attach a separate sheet if needed)
Name__________________________________________SSN**_____________________License #______________________
Name__________________________________________SSN**_____________________License #______________________
Name__________________________________________SSN**_____________________License #______________________
Name__________________________________________SSN**_____________________License #______________________
*Note: If you are not a current California licensee (resident or non-resident), a separate application form 441-9 must be completed by each
person name above.
18. Business Entity Disclosure: Identify all partners, members, officers, directors, managers, controlling persons and any shareholders
owning 10% or more interest in the business entity. (Attach separate sheet if more space is needed)
Name___________________________ Title ______________ SSN/FEIN**___________________ % of ownership_________
Name___________________________ Title ______________ SSN/FEIN**___________________ % of ownership_________
Name___________________________ Title ______________ SSN/FEIN**___________________ % of ownership_________
Name___________________________ Title ______________ SSN/FEIN**___________________ % of ownership_________
Name___________________________ Title ______________ SSN/FEIN**___________________ % of ownership_________
Name___________________________ Title ______________ SSN/FEIN**___________________ % of ownership_________
Name___________________________ Title ______________ SSN/FEIN**___________________ % of ownership_________
Name___________________________ Title ______________ SSN/FEIN**___________________ % of ownership_________
Name___________________________ Title ______________ SSN/FEIN**___________________ % of ownership_________
Name___________________________ Title ______________ SSN/FEIN**___________________ % of ownership_________
19. Controlling Person(s): (Attach separate sheet if more space is needed)
A "Controlling Person" as defined in section 1668.5 (b) is the following: If you are listing a individual, corporation, partnership, limited liability
company, limited partnership, holding company or trust in section #18, then you must identify the Controlling Person or Persons, including the
president, chief executive officer, chairman of the board, those people that own 10% or more of the stock and any other person who directly or
indirectly possess the power to control the affairs of the business entity.
Name___________________________ Title ______________ SSN/FEIN**___________________ % of ownership_________
Name___________________________ Title ______________ SSN/FEIN**___________________ % of ownership_________
Name___________________________ Title ______________ SSN/FEIN**___________________ % of ownership_________
Name___________________________ Title ______________ SSN/FEIN**___________________ % of ownership_________
**Disclosure of your U. S. social security number is mandatory pursuant to; Cal. Family Code, §17520(d); the Federal Tax Reform Act of
1976 (42 U.S.C. §405(c)(2)(C)(i)) and the Federal Welfare Reform Act of 1996 (42 U.S.C. §666). If you fail to disclose your social security
number, your application will not be reviewed. An individual has a right of access to certain records containing personal information
pertaining to that individual. Individuals may obtain information regarding the location of their records by contacting the Bureau Chief,
Producer Licensing Bureau, California Department of Insurance by telephone (800-967-9331) or by mail to the following address: 320
Capitol Mall, Sacramento CA 95814.
Page 2 of 6 LIC 441-11 (Rev 12/2018)
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_____________________________________________________________________________
_________________________________________________________________________________________________________________
_________________________________________________________________________________________________________
20. Surplus Line and/or Special Lines’ Surplus Line Applicants only: Notification of your filing for a Surplus Line Brokers’ license will be
forwarded to the Surplus Line Association of California, who will notify you as to their filing rules (California Code of Regulations, Title 10,
Section 2172).
List names of all insurers not admitted to California with whom arrangements have been made to accept or who are considering the
acceptance of surplus line business offered by the business entity:
Surplus Line or Special Lines’ Surplus Lines Business Entity Endorsement Authorization
List name of each person applying to transact under the authority of this license type.
Name________________________________________________SSN**____________________License #______________________
Name________________________________________________SSN**____________________License #______________________
Name________________________________________________SSN**____________________License #______________________
Background Questions
If you fail to fully disclose any information that is required or if you make a false statement, your application may be denied.
Federal law (18 U.S.C. 1033) prohibits anyone who has been convicted of a felony involving dishonesty or a breach of trust or who has been
convicted of any violation of 18 U.S.C. 1033 and 1034 from engaging in the business of insurance unless they have obtained the written
consent of the Insurance Commissioner. It is a violation of this statute to engage in the business of insurance without the Commissioner’s
written consent. Further, it is a criminal offense for any person to willfully employ, or willfully permit, such "prohibited persons" to engage in
the business of insurance without the required written consent.
A "Prohibited Person" may be an officer, director or employee of an insurance agency or an insurance company, an agent, solicitor, broker,
consultant, third party administrator, managing general agent, or subcontractor representing an insurance agency or insurance company who
engages in or transacts the business of insurance. If you have a “Prohibited Person” in your organization that meets this criteria and has
been convicted of a felony involving dishonesty or a breach of trust or a violation of 18 U.S.C. 1033 and 1034, then the “Prohibited Person”
must obtain written consent prior to filing this application.
DO NOT SUBMIT THIS APPLICATION UNTIL THE PROHIBITED PERSON HAS FILED FOR WRITTEN CONSENT FROM THE
COMMISSIONER. If they have received consent, a copy of their consent letter must be attached to this application. If you are applying for a
non-resident license, attach a copy of the written consent letter issued by their home state. Instructions to apply for the written consent are
available on the CDI’s Web site at www.insurance.ca.gov
.
21. Has the business entity or any of its partners, members, controlling persons, officers, directors, managers, or any
shareholders owning 10% or more interest in the business entity, ever been convicted of, or is the business entity or,
any partner, member, controlling person officer, director, manager or any shareholders owning 10% or more interest in
Yes No
the business entity currently charged with, committing a crime, whether or not adjudication was
withheld?…………………………………………………………………………………………
“Crime” includes a felony, a misdemeanor or 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 nolo contendere, no contest, having had any
charge expunged, dismissed or plea withdrawn pursuant to Penal Code Section 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 should answer "yes" if you have been convicted of a felony or a misdemeanor including driving offenses
such as, but not limited to reckless driving, driving under the influence and driving with a suspended license, whether or
not you spent any time in jail, and whether or not you believe the conviction has been removed from your record.
If you answer yes, you must attach to this application:
a) a written statement with original signature explaining the circumstances of each incident,
b) a certified copy of the charging document, and a certified copy of the official document which
demonstrates the resolution of the charges or any final judgment.
*Disclosure of your U. S. social security number is mandatory pursuant to; Cal. Family Code, §17520(d); the Federal Tax Reform Act of
1976 (42 U.S.C. §405(c)(2)(C)(i)) and the Federal Welfare Reform Act of 1996 (42 U.S.C. §666). If you fail to disclose your social security
number, your application will not be reviewed. An individual has a right of access to certain records containing personal information
pertaining to that individual. Individuals may obtain information regarding the location of their records by contacting the Bureau Chief,
Producer Licensing Bureau, California Department of Insurance by telephone (800-967-9331) or by mail to the following address: 320
Capitol Mall, Sacramento CA 95814.
Page 3 of 6 LIC 441-11 (Rev 12/2018)
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Background Information continued
If you fail to fully disclose any information that is required or if you make a false statement, your application may be denied.
22. Has the business entity or any of its partners, members, controlling persons, officers, directors, managers or any
shareholders owning 10% or more interest in the business entity, ever been involved in an administrative proceeding
regarding any professional or occupational license?
“Involved” means having a license censured, suspended, revoked, canceled, terminated or, being assessed a fine,
placed on probation 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.
“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, you must attach to this application:
a.
a written statement with original signature identifying the type of license and explaining the circumstances of
incident; and
b. a certified copy of the Notice of Hearing or other document that states the charges and allegations; and,
c. a certified copy of the official document which demonstrates the resolution of the charges or any final judgment.
Yes No
23. Has any demand been made or judgment rendered against the business entity or any of its partners, members,
controlling persons, officers, directors, managers or any shareholders owning 10% or more interest in the business
entity for overdue monies by an insurer, insured or producer, or have you ever been subject to a bankruptcy
proceeding?
If you answer “yes,” submit a statement summarizing the details of the indebtedness and arrangements for repayment.
Yes No
24. Has the business entity or any of its partners, members, controlling persons, officers, directors, managers or any
shareholders owning 10% or more interest in the business entity, 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?
If you answer yes, identify the jurisdiction(s): _______________________________________
Yes No
25. Has the business entity or any of its partners, members, controlling persons, officers, directors, managers or any
shareholders owning 10% or more interest in the business entity, been 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?
If you answer yes, you must attach to this application:
a. a written statement with original signature summarizing the details of each incident; and
b. a copy of the Petition, Complaint or other document that commenced the lawsuit or arbitration; and,
c. a copy of the official document which demonstrates the resolution of the charges or any final judgment.
Yes No
26. Has the business entity or any of its partners, members, controlling persons, officers, directors, managers or any
shareholders owning 10% or more interest in the business entity, ever had an insurance agency contract or any other
business relationship with an insurance company terminated for any alleged misconduct?
If you answer yes, you must attach to this application:
a. a written statement with original signature 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.
Yes No
Page 4 of 6 LIC 441-11 (Rev 12/2018)
J
Important Notice for Limited Liability Companies:
Section 1647.5(c) of the California Insurance Code (CIC) requires each Limited Liability Company, at the time of licensing pursuant to this
chapter and, with respect to surplus line brokers, Chapter 6, and at all times during which the company holds an active license, is required
to file with the Insurance Commissioner an annual confirmation demonstrating continuing compliance with the financial security requirements of
Section 1647.5 CIC. This annual confirmation is typically satisfied by submitting proof of errors and omissions liability insurance coverage. The
aggregate dollar amount of errors and omissions coverage can be in the form of cash, bonds, bank certificates of deposit, U.S. Treasury
obligations, etc., held to provide security for claims against the Limited Liability Company. (The amount required over the minimum of
$500,000 is at least $100,000 multiplied by the number of licensees rendering professional services on behalf of the company; however, the
maximum amount is not required to exceed $5,000,000.00.)
For the purposes of satisfying this requirement, you are required to provide one of the following:
1. Complete and return the enclosed Certificate of Coverage (Form LIC CC1) signed by a representative of the insurance company providing
the errors and omissions policy (Form LIC CC1 is available from the departmental website at www.insurance.ca.gov); or,
2. If assets other than the errors and omissions liability insurance are being used to satisfy the security requirements, provide verification from
the bank or escrow holder listing the type of asset and the current dollar amount.
Applicant’s Certification:
I (we) certify (or declare) under penalty of perjury that:
a. the named business entity intends actively and in good faith to carry on an insurance business with the general public;
b. the business entity's articles of incorporation or articles of organization or association or partnership agreement, as the case may be, do
not forbid it to act in the capacity for which this application is being made;
c. the holding of the license hereby applied for is not incompatible with the laws, rules or regulations of any federal, state, county or municipal
government for which it performs work (if any) by which it is licensed (if any);
d. if the license is granted, only those natural persons so authorized will transact insurance under each license;
e. (Surplus Line and Special Lines' applicants only) - we apply for a license pursuant to the provisions of Chapter 6, Part 2, Division 1 of the
Insurance Code of the State of California permitting the solicitation, negotiation and subject to the provision of said Chapter, the effecting
of insurance to be procured from or placed with insurers not authorized to transact insurance business in this State.
Further, I (we) certify (or declare) under penalty of perjury that I (we) have read the foregoing application and know the contents thereof and
that each statement therein made is full, true and correct. I (we) understand that pursuant to Sections 1668 (h) and 1738 of the Insurance
Code, any false statements may subject my application to denial and may subject my license(s) to suspension or revocation. Further, pursuant
to Insurance Code Sections 1703 and 1733, I (we) authorize disclosure to the Insurance Commissioner of all financial institution records of any
fiduciary accounts for the duration of this license.
IMPORTANT NOTICE
Signature(s) __________________________________ Title ___________________________________
If organization is a partnership,
_____________________________________ Title____________________________________
each partner must sign this
(type name) (type title) and title)
application.
______________________________________ Title ___________________________________
If organization is a corporation,
an officer having authority to
_____________________________________ Title____________________________________
bind the organization must
(type name) (type title) and title)
sign.
_____________________________________ Title ____________________________________
If organization is a limited
liability company, an officer,
_____________________________________ Title____________________________________
member or manager having
(type name) (type title) and title)
authority to bind the
organization must sign.
Date Executed ________________________________, at ___________________, ______
If organization is a nonprofit
(month, day, year) (city) (state)
corporation or unincorporated
association, all members must
sign.
All fees are filing fees and are not refundable or transferable, whether or not the application is acted upon or the examination taken.
Page 5 of 6 LIC 441-11 (Rev 12/2018)
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Instructions for completing Business Entity application
Re: "Business Entity type": Corporation- if already incorporated, attach a copy of your Certificate of Good Standing. If corporation has been formed as a result of a merger,
submit a copy of your approved merger papers.
Re: "Limited Liability Company" - attach a copy of your approved articles of organization. Additional requirements are listed on page 4. This documentation must be submitted
with your application.
Re: "Business Entity Name": The true business entity name must be entered. Include commas, hyphens, ampersands, etc. This name is subject to disapproval by the
Insurance Commissioner.
Re: "Fictitious Name": If you intend to transact insurance in a name other than the true business entity name, enter such fictitious name. This name is subject to disapproval
by the Insurance Commissioner.
Re: "Designated/Responsible Licensed Producer": You must list all licensed producers intending to transact on behalf of the business entity. All unlicensed producers
intending to transact on behalf of the business entity must complete form 441-9.
Re: "Controlling Person": Insurance Code Section 1668.5(b), in part, defines a "controlling person" as a person who possesses the power to direct or cause the direction of
the management and policies of the business entity.
Re: "Background Information": If the answer is "yes" to any of these questions, you must submit required documentation.
Re: "Applicant’s Certification": Partnership - each partner of the partnership must sign. Corporation Limited Liability Company or Association - an officer having authority to
bind the Corporation or Association must sign.
A) Licenses are issued for a two-year term, which begins the date the first license is issued to the business entity and ends the last day of that calendar month two years later.
Subsequent licenses are issued for the balance of the established license term.
B) Fees: Filing fees are required for each business entity application submitted, except that Surplus Line or Special Lines' fees may vary - see below:
Surplus and Special Surplus Lines Filing fees: $1,296 (two year term), the fee for an individual surplus line broker that has a $50,000
bond on file.
Direct questions regarding this filing to the Producer Licensing Bureau in Sacramento, (916) 492-3069.
All fees are filing fees and are not refundable, whether or not the application is acted upon or an examination taken. Mail application with fees to: Department of Insurance,
P.O. Box 1139, Sacramento, CA 95812-1139.
Notice: Information Collection and Access Section 31(e) of the California Business and Professional Code allows the State Board of Equalization and the Franchise
Tax Board to share taxpayer information and requires the licensee to pay his or her state tax obligation. Section 31 also states that the license may be suspended if
the state tax obligation is not paid.
Section 1798.17 of the California Civil Code requires the following information to be provided when collecting information from individuals to determine compliance with the group
and corporate practice provisions of the law, and to establish positive identification, to match the names of the certified list provided by the Department of Child Support Services
to applicants and licensees, and of responding to requests for this information made by child support agencies.
Agency: Department of Insurance, Address: 320 Capitol Mall, Sacramento, Ca 95814-4309, Telephone: (800) 967-9331.
Title of official responsible for information maintenance: Chief, Producer Licensing Bureau
Authority which authorizes the maintenance of the information: California Insurance Code, Chapters 5, 6, 7, 8-Part 2, Division 1
The consequences, if any, of not providing all or part of the requested information: It is mandatory that you provide all information requested. Omission of any item of requested
information will result in the application being rejected as incomplete.
The principal purposes for which the information is to be used: The information requested will be used to determine qualifications for licensure or certification, to determine
compliance with the group and corporate practice provisions of the law and to establish positive identification.
Each individual has the right to review files maintained on them by the agency, unless the information is classified as confidential under section 1798.3(a) of the California Civil
Code.
Page 6 of 6 LIC 441-11 (Rev 12/2018)
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Business Entity Application for Insurance License (California)

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Completed 13 April 2021

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