Fillable FORM L-191: NAIC UNIFORM APPLICATION FOR Individual Renewal (Arizona)

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FORM L-191: NAIC UNIFORM APPLICATION FOR Individual Renewal (Arizona)

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Page 1 of 3 AZDIFI Form L-191 Instructions 20220601
AZDIFI
FORM L-191
INSTRUCTIONS
NAIC UNIFORM APPLICATION FOR
Individual Renewal
LICENSING
602-364-4457 |
insurancelicensing@difi.az.gov
FOR USE IN APPLYING FOR AN INITIAL INSURANCE LICENSE OR ADDING A LINE OF AUTHORITY FOR AN INDIVIDUAL.
TIME SENSITIVE MATERIALS!
IMPORTANT! If the Insurance Licensing Section does not receive your complete application and fees BY OR BEFORE
YOUR LICENSE EXPIRATION DATE, you will lose the authority to transact insurance, and you will need to pay an additional
$100 late fee to renew the license. See A.R.S. § 20-289(E).
IF WE RECEIVE YOUR RENEWAL APPLICATION MORE THAN ONE YEAR AFTER THE LICENSE EXPIRES, WE WILL RETURN IT TO YOU.
You will then need to submit an application for a new license and fulfill all of requirements for obtaining a new license.
AS AN ALTERNATIVE, you may renew your license online using the National Insurance Producer Registry
(NIPR) found at https://nipr.com/
instead of submitting this Form L-191. NIPR applications are processed more
quickly. Do not submit this form and also renew online.
CAREFULLY READ THESE INSTRUCTIONS. You may need to submit additional forms or documents with your
application. If your application does not contain all the necessary forms or documents, or is otherwise not
complete, the application will be returned as deficient.
KEEP THESE INSTRUCTIONS – DO NOT RETURN THEM with your license application.
DO NOT use Form NAIC Uniform Application for Individual Renewal …
• To apply for a license or to add license authority to an existing license: See the department’s website at
https://difi.az.gov/
for instructions on how to apply for new license authority.
• To apply to renew the license of a business entity: Apply online at https://nipr.com/.
IF SUBMITTING YOUR APPLICATION IN PAPER FORMAT:
• Clearly print in ink or type all information.
• Ensure the application is complete.
Mail or deliver the completed application with all required documents and fees to:
INSURANCE LICENSING SECTION, 100 N 15 AVENUE, SUITE 261, PHOENIX, AZ 85007-2630
QUESTIONS?
Before calling, look for answers on the department’s Internet website found at https://difi.az.gov/
. For questions not
addressed on our website, contact the Insurance Licensing Section:
E-mail: InsuranceLicensing@difi.az.gov
Phone: 602-364-4457
LICENSE CERTIFICATES: The department does not print license certificates. View your license online using the License
Search option on the department’s website (https://difi.az.gov/). Click the “Licensing” tab on the home page.
FORM L-191 INSTRUCTIONS
Page 2 of 3 AZDIFI Form L-191 Instructions 20220601
DEMOGRAPHIC INFORMATION
• Your business address
MUST BE THE PHYSICAL STREET ADDRESS accessible to the public where you transact
insurance (not a post office box or postal mail box). If you conduct business from your home, enter the address of
your home in this section.
• You may use a street address, post office box (or PMB) as your mailing address.
• Please fully complete this section of the form.
AGENCY OR BUSINESS ENTITY AFFILIATIONS
This is not a required field. Any information entered will not be tracked by the department.
BACKGROUND INFORMATION
If you answer “Yes” to one or more of these questions, include:
a. A signed statement describing in detail all incidents including
• names of all parties involved,
• dates and locations,
• the names and localities of any courts and/or administrative agencies involved,
• the disposition of each matter,
• whether the conviction, plea or finding was for a felony or open-ended charge;
AND
b. 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 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.
IMPORTANT!
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.
CONTINUING EDUCATION
Continuing education (“CE”) requirements applicable to Arizona-resident insurance producers have changed. For more
information, please visit the department’s website online at (https://
https://difi.az.gov/producers/producer-
agentbroker.az.gov/ice).
• Non-residents are not required to complete CE if the non-resident fulfills resident state CE requirements.
• An Arizona resident who holds a major-line insurance producer license may be required to complete insurance
continuing education.
• A person that does not hold a major-line insurance producer license (such as a credit insurance producer, an
insurance adjuster, a bail bond agent, etc.) does not have an insurance continuing education requirement.
• If you are required to complete insurance CE, do not wait until the end of your license term to try to fulfill CE
requirements. Not only must you register for and complete the CE, but the CE provider must issue to you a
Certificate of Completion and must report your course completion to Prometric. This can take time, which could result
FORM L-191 INSTRUCTIONS
Page 3 of 3 AZDIFI Form L-191 Instructions 20220601
in your not meeting license renewal requirements and expose you to the risks of losing your authority to transact
insurance and to having to pay a late renewal fee.
FEES
For a new license
OR to add authority to an existing license:
Fees are NON-REFUNDABLE and are not prorated [A.R.S. § 20-167(B)].
Make your check or money order payable to INSURANCE LICENSING SECTION.
Insurance License Fee ..............................................
$120.00
PER LICENSE CLASS
TYPE REQUESTED
Adjuster
Bail Bond Agent
Insurance Producer
Portable Electronics Vendor
Rental Car Agent
Risk Management Consultant
Self Service Storage Agent
Surplus Lines Broker License Fee...........................
• Surplus Lines Broker
$100.00 to add authority to an existing license that
expires in two years or less;
Life Settlement Broker License Fee.........................
$500.00 for authority that expires in more than two
years.
Navigator and/or Certified Application Counselor .
$0.00
THE ARIZONA DEPARTMENT OF INSURANCE IS AN EQUAL EMPLOYMENT OPPORTUNITY AGENCY THAT
COMPLIES WITH THE AMERICANS WITH DISABILITIES ACT ("ADA”) OF 1990. PERSONS WITH DISABILITIES MAY
REQUEST ACCOMMODATION BY CONTACTING THE ADA COORDINATOR AT 602-364-3471. REQUESTS SHOULD
BE MADE AS EARLY AS POSSILE TO ALLOW TIME FOR THE DEPARTMENT TO MAKE APPROPRIATE
ARRANGEMENTS.
© 2011 National Association of Insurance Commissioners Page 1 of 3
Uniform Application for
Individual Producer License Renewal/Continuation
(Please Print or Type)
Check appropriate box for license requested.
Resident License
Non-Resident License
Identify Home State:
Identify Home State License #:
Demographic Information
1
Soc. Security Number
_ _
2
Date of Birth
3
If assigned National Producer
Number (NP#)
4
Last Name
JR./SR. etc
5
First Name
5
Residence/Home Address (Physical Street)
6 Individual Applicants Email Address:
7
City
8
State
9
Zip or Foreign Country
10
Business Entity’s Name
11
Business Address (Physical Street)
12
P.O. Box
13
City
14
State
15
Zip or Foreign Country
16
Business Phone Number (include
extension)
17
Business Fax Number
18
Business E-Mail Address
19
Business Web Site Address
20
Mailing Address
21
P.O. Box
22
City
23
State
24
Zip or Foreign
Country
Agency or Business Entity Affiliations
25
List your Insurance Agency Affiliations: (Complete only if the applicant is to be licensed as an active member of the business entity)
FEIN NPN Name of Agency
FEIN NPN Name of Agency
FEIN NPN Name of Agency
Background Information
26
1. Have you been convicted of a crime, had a judgment withheld or deferred, or are you currently charged with committing a crime, which has
not been previously reported to this insurance department?
Yes No
Note: “Crime” includes a misdemeanor, a felony or a military offense.
You may exclude misdemeanor traffic citations and misdemeanor convictions or pending misdemeanor charges involving driving under
the influence (DUI) or driving while intoxicated (DWI), driving without a license, reckless driving, or driving with a suspended or
revoked license and juvenile offenses.
“Convicted” includes, but is not limited to, having been found guilty by verdict of a judge or jury, having entered a plea of guilty or nolo
contendere or no contest, or having been given probation, a suspended sentence or a fine.
If you answer yes, you must attach to this application:
a) a written statement explaining the circumstances of each incident,
b) a copy of the charging document,
c) a copy of the official document, which demonstrates the resolution of the charges or any final judgment.
If you have a felony conviction involving dishonesty or breach of trust, have you applied for written consent to engage in the business of
insurance in your home state as required by 18 USC 1033? N/A Yes No
If so, was that consent granted? (Attach copy of 1033 consent approved by home state.) N/A Yes No
© 2011 National Association of Insurance Commissioners Page 2 of 3
Uniform Application for
Individual Producer License Renewal/Continuation
Background Information continued
2. Have you been named or involved as a party in an administrative proceeding, including a FINRA sanction or arbitration proceeding regarding
any professional or occupational license or registration, which has not been previously reported to this insurance department?
Yes No
“Involved” means having a license censured, suspended, revoked, canceled, terminated; or, being assessed a fine, placed on probation,
sanctioned 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, or registration. “Involved” also means having a license,
or registration, application denied or the act of withdrawing an application to avoid a denial. INCLUDE any business so named because of
your actions in your capacity as an owner, partner, officer or director, or member or manager of a Limited Liability Company. 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 identifying the type of license and explaining the circumstances of each incident,
b) a copy of the Notice of Hearing or other document that states the charges and allegations, and
c) a copy of the official document which demonstrates the resolution of the charges or any final judgment.
3. Do you have a child support obligation in arrearage, which has not been previously reported to this insurance department?
If you answer yes,
a) by how many months are you in arrearage?
b) are you currently subject to and in compliance with any repayment agreement?
c) are you the subject of a child support related subpoena/warrant?
4. In response to a “yes” answer to one or more of the Background Questions for this renewal application, are you submitting document(s) to the
NAIC/NIPR Attachments Warehouse?
If you answer yes
Will you be associating (linking) previously filed documents from the NAIC/NIPR Attachments Warehouse to this application?
Note: If you have previously submitted documents to the Attachments Warehouse that are intended to be filed with this renewal
application, you must go to the Attachments Warehouse and associate (link) the supporting document(s) to this application based
upon the particular background question number you have answered yes to on this application. You will receive information in a
follow-up page at the end of the application process, providing a link to the Attachment Warehouse instructions.
Yes No
Months
Yes No
Yes No
N/A
Yes No
Yes No
© 2011 National Association of Insurance Commissioners Page 3 of 3
Uniform Application for
Individual Producer License Renewal/Continuation
Applicant’s Certification and Attestation
27
The producer must read the following very carefully:
1. I hereby certify that, under penalty of perjury, all of the information submitted in this application and attachments is true and complete. I am aware that submitting
false information or omitting pertinent or material information in connection with this application is grounds for license revocation or denial of the license and may
subject me to civil or criminal penalties.
2. Unless provided otherwise by law or regulation of the jurisdiction, I hereby designate the Commissioner, Director or Superintendent of Insurance, or other
appropriate party in each jurisdiction for which this application is made to be my agent for service of process regarding all insurance matters in the respective
jurisdiction and agree that service upon the Commissioner, Director or Superintendent of Insurance, or other appropriate party of that jurisdiction is of the same legal
force and validity as personal service upon myself.
3. I further certify that I grant permission to the Commissioner, Director or Superintendent of Insurance, or other appropriate party in each jurisdiction for which this
application is made to verify information with any federal, state or local government agency, current or former employer, or insurance company.
4. I further certify that, under penalty of perjury, a) I have no child-support obligation, b) I have a child-support obligation and I am currently in compliance with that
obligation, or c) I have identified my child support obligation arrearage on this application.
5. I authorize the jurisdictions to which this application is made to give any information concerning me, as permitted by law, to any federal, state or municipal agency,
or any other organization and I release the jurisdictions and any person acting on their behalf from any and all liability of whatever nature by reason of furnishing
such information.
6. I acknowledge that I understand and will comply with the insurance laws and regulations of the jurisdictions to which I am applying for licensure.
7. I hereby certify that upon request, I will furnish the jurisdiction(s) to which I am applying, certified copies of any documents attached to this application or requested
by the jurisdiction(s).
Month/Day/Year
Original Producer Signature
Full Legal Name (Printed or Typed)
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FORM L-191: NAIC UNIFORM APPLICATION FOR Individual Renewal (Arizona)

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Completed 1 July 2022

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