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,
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.
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
the business entity currently charged with, committing a crime, whether or not adjudication was
“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)