1351 West North Street, Suite 101, Dover, DE 19904 • insurance.delaware.gov
(302) 674-7300 Dover • (302) 739-5280 fax • (302) 577-5280 Wilmington
General Partnership Limited Partnership
Name and Address of Partners (identify limited partners, if any):
If a
pplicant has engaged previously in same or similar business, provide details, including name(s), address and
date first commenced:
Appl
icant is directly or indirectly under common ownership, control or management, or is otherwise affiliated or
associated with any insurer, or any person, firm or corporation having or exercising control of an insurer.
Yes (Supply complete details) No
Date
of Current Certified Annual Statement (attach)
Addit
ional business conducted at the address of the applicant
Nam
e & Address of additional place of business for applicant, any subsidiary, affiliated or associated Insurance
Premium Finance Company:
Has applicant, manager, any officer, director, owner or beneficial owner of 10% or more of the shares (If yes,
submit complete details including name, address, disposition of charges, etc.):
1. Applied previously in this State for a license to engage in the business of insurance premium financing?
Yes No
2. Received a rejection, revocation or suspension of license under laws of this State governing insurance
premium or other customer financing?
Yes No
3. Received a rejection, revocation or suspension under an insurance premium financing law or regulation,
or similar law or regulation in any other State?
Yes No
4. Received a revocation or suspension of any license, been convicted or entered a plea of guilty, or nolo
contendere with respect to any law or regulation relating to the business of insurance?
Yes No
5. Been arrested, indicted, convicted, entered a plea of guilty or nolo contendere with respect to a State or
Federal offense in this or any other State?
Yes No
6. Been placed in voluntary or involuntary bankruptcy, receivership, trusteeship, or conservatorship?
Yes No
7. Hold a license to engage in the business of insurance premium financing or a similar or related business
in any State, District or Territory of the United States?
Yes No
Date
of Signature
Signature of Officer
Printed Name
Title
Ple
ase enclose a check for $500.00 made payable to the Delaware Department of Insurance.
Partnership
click to sign
signature
click to edit
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