Page 2 of 2 Form L-169 (v. 20150319)
SECTION IV: INSURANCE LICENSE HISTORY Are you now, or have you ever been, licensed to transact any kind of insurance in
this state or elsewhere? Yes
No If “Yes,” attach a list of the insurance licenses you held and, for each, the license number, the line(s)
of insurance on the license, the state or locality that issued the license, the date the license was issued and the license expiration date.
SECTION V: ADDITIONAL INFORMATION 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. NOTE: ADDITIONAL
INFORMATION IS REQUIRED if you respond “YES” to any of the following. Please see INSTRUCTIONS.
For the purposes of this application, "judgment" includes, but is not limited to, having been found guilty by judge or jury or pled guilty or no
contest to any charge. You must answer “Yes” even if a conviction was dismissed, expunged, pardoned, appealed, set aside, vacated or
reversed, etc., OR even if you had civil rights restored, had a plea withdrawn, or were given probation, a suspended sentence, a fine, or
successfully completed a diversion program. You must answer “Yes” even if your conviction was initially labeled an undesignated offense.
A Have you EVER had any professional, vocational, business license or certification refused, denied, suspended,
revoked or restricted, OR been issued a consent order, an administrative action OR a fine imposed by any public
authority?
Yes No
B. Have you EVER withdrawn an application for a license or certification to avoid its denial, or have you EVER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. Have you 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? ..............................................................................................................................................................
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 you in any jurisdiction accusing you of any issue listed in Question C?: ............
Yes No
E. If you ARE NOT applying for a bail bond agent license, answer “Not applicable.”
Not applicable
If you ARE applying for a bail bond agent license, have you EVER been convicted in any jurisdiction of any
crime (felony, open-ended or misdemeanor, etc.) that involved theft OR carrying, illegally using or possessing a
deadly weapon or dangerous instrument? .....................................................................................................................
Yes No
SECTION VI: EMPLOYMENT HISTORY List your employment, insurance and non-insurance, history (and periods of
unemployment or education) for the past 5 years. If you need more space, attach and sign a separate sheet with the information.
Employer Name
Position Held
City/State
EMPLOYMENT DATES
FROM (mm/yy) TO (mm/yy)
SECTION VII: AUTHORIZATION AND RELEASE By signing and submitting this application, you agree to all the following.
You authorize the Arizona Department of Insurance (“DEPARTMENT”) to conduct a background investigation to determine your fitness for
an insurance license. You agree to promptly respond to questions that may arise from the investigation.
You authorize and request every person, firm, company, corporation, governmental agency, court, association or institution having control of
any documents, records and other information about you to furnish the DEPARTMENT with any such information and you permit the
DEPARTMENT, its employees, agents or representatives, and your authorized insurers, to inspect and make copies of such documents,
records and other information.
You release, discharge and exonerate the DEPARTMENT, its employees, agents and representatives, the State of Arizona, your authorized
insurers, and any person furnishing information pursuant to this Authorization and Release from any and all liability that may arise from the
investigation made by the DEPARTMENT.
You attest that you read, understood and followed the five-page INTRUCTIONS FOR FORM L-169 document.
You attest that you have read and understand the foregoing. You certify, under penalty of denial, suspension or revocation of the
license and under any other penalties that may apply that the answers, statements and information furnished in connection with this license
application are true, correct and complete to the best of your knowledge and belief.
__________________________________________ _____________________________________________
Printed Name of Applicant Full Signature of Applicant
SECTION VII ATTESTATION INCOMPLETE
YOUR APPLICATION IS INCOMPLETE. Please make the following corrections:
* Top of first page, # 1: Explain why you are not using NIPR to submit your license application.
* SECTION II: Select one or more lines of license authority.
* SECTION II: Select an option on the right side of the section.
* SECTION V: You must answer all of the questions in the section.
