Fillable Individual Application For Insurance License (California)

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Individual Application For Insurance License (California)

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The Individual Application For Insurance License (California) form is 5 pages long and contains:

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  • 26 check-boxes
  • 122 other fields

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State of California
Department of Insurance
Individual Application For Insurance License
LIC-441-9 (Rev 01/2021)
1. Application Type: Permanent Certificate of Convenience
For Department Use Only
License #
2. License Type:
Accident & Health or Sickness (AH)
Life Agent (LO)
Variable Life and Variable Annuity (VC)
Property Broker-Agent (PR)
Casualty Broker-Agent (CA)
Personal Lines Broker-Agent (PL)
Limited Lines Auto Insurance Agent (AU)
Credit Insurance Agent (CI)
Part Time Fraternal Agent (PF)
Portable Electronics Agent (PE)
Car Rental Agent (RC)
Surplus Line Broker (SL)*
Special Lines’ Surplus Line Broker (SP)*
Self-Service Storage Agent (SS)
Title Marketing (TM)
Burial and Funeral Expenses (LOLP)
Life & Disability Analyst (LA)
Motor Club Agent (MC)
Cargo Shipper’s Agent (CS)
Vehicle Service Contract
Provider (VS)
3. Last Name First Name Middle Name Suffix
4. Male Female
5. Birthdate (MM/DD/YYYY) 6. Social Security Number or Individual Tax Identification Number**
7.
Resident Address (P.O. Box not acceptable) 8. City
9. State
10. Zip Code
11. Home Phone Number
12. Are you a citizen of the United States? Yes No
13. Are you affiliated with a
financial institution/bank?
Yes No
14. Business Address (P.O. Box not acceptable.)
15. City
16. State
17. Zip Code
19. Business Fax Number
20. E-mail Address (required)
21. Business Web Site Address
22. Mailing Address (P.O. Box is acceptable.)
23. City
24. State
25. Zip Code
26. Special Accommodation Request for Examination - If required, arrangements were made prior to taking and passing
the license examination.
27. Examination Information: If required, you must first pass your license examination before submitting this license
application. After you pass your license examination, please ensure that all required documents are submitted. If you are
required to submit documents, please email them to: CADepartmentofInsuranceLicensingExams@insurance.ca.gov or send
them to: CA Dept. of Insurance, Attention: Individual License Application, 320 Capitol Mall, Sacramento, CA 95814-4309
*Form LIC 050 must be completed and submitted with Surplus and/or the Special Lines’ Surplus Broker Application.
**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 or your individual tax identification 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. Or an Individual Tax Identification Number issued by the Internal Revenue Service pursuant to Cal. Insurance Code,
§1666.5(a)(2).
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28. Work/Personal History: Account for all time for the past five years. Give all employment experiences starting with your
current employer working back five years. Include full and part-time work, self-employment, military service, unemployment,
and full-time education. Attach separate sheet, if needed.
From
Month Year
To
Month Year
Position Held
Name
City State
Name
City State
Name
City State
Name
City State
29. Do you now hold, or have you ever held, an insurance license as a resident in this state or any other state?
Yes No
Type of License
State or Province
Date License Held
Is License in Force?
30. AKA/Alias
Are you now using or have you ever used any name other than shown? Yes No
If yes, list names, dates and reason(s) used:
Last First Middle Suffix Dates Used Reason Used
Last First Middle Suffix Dates Used Reason Used
31. Fictitious Names:
Do you intend to use a fictitious (DBA) name?
If yes, list the name: (This name must be approved by the Department prior to use) Yes No
32. Life-Only Agent/Part Time Fraternal License Applicants Only:
Are you registered with the Securities and Exchange Commission (SEC) or Financial Industry Regulatory Authority (FINRA)?
Yes No
Central Registration Depository Number (CRD) If CRD# is not provided, acceptable proof of registration
must be attached before the authority may be granted. If acceptable proof is not submitted, license will be issued without
variable life and variable annuity authority.
33. Prelicensing Certificates:
Do you certify that you have completed your prelicensing education? Yes No
If no, your prelicensing education must be completed prior to taking your examination.
If yes, you must provide the completion date:
Page 2 of 6 LIC 441-9 ( 01/2021)
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34.
Background Information
If you fail to fully disclose any information that is requested or
if you make a false statement, your application may be denied.
1. Have you ever been convicted of a felony?
For the purpose of this application, you have been “convicted” if you were ever found guilty by verdict of a
judge or jury; and/or ever entered a plea of guilty, nolo contendere or no contest. You must disclose all
convictions, even if the charges were later dismissed or expunged, your guilty plea was withdrawn pursuant
to Penal Code Section 1203.4, or you were placed on probation, received a suspended sentence or just
ordered to pay a fine. If you fail to disclose all convictions, your application may be denied. You may exclude
juvenile offenses tried in juvenile court.
If you answer “Yes” to this background question, you must attach to this application:
a) a written statement, with original signature, explaining the circumstances of each conviction or charge;
and,
b) certified copies of the charging documents, and of the court documents which detail the conviction,
resolution of the charges, probation and any final judgment.
Yes No
2. 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. If
you have been convicted of a felony involving dishonesty or a breach of trust or a violation of 18 U.S.C. 1033
and 1034, then you must attach a copy of this consent. If you have not obtained this written consent, you
must do so prior to filing your application
.
a. Have you ever been convicted of a felony involving dishonesty or a breach of trust?
For the purpose of this application, you have been “convicted” if you were ever found guilty by verdict of a
judge or jury; and/or ever entered a plea of guilty, nolo contendere or no contest. You must disclose all
convictions, even if the charges were later dismissed or expunged, your guilty plea was withdrawn pursuant
to Penal Code Section 1203.4, or you were placed on probation, received a suspended sentence or just
ordered to pay a fine. If you fail to disclose all convictions, your application may be denied. You may exclude
juvenile offenses tried in juvenile court.
If you answered “Yes” to background question 2a, you must attach to this application:
i. a written statement, with original signature, explaining the circumstances of each conviction or charge; and,
ii. certified copies of the charging documents, and of the court documents which detail the conviction,
resolution of the charges, probation and any final judgment.
b. If you have been convicted of a felony involving dishonesty or a breach of trust, have you received written
consent from the California Insurance Commissioner to engage in the business of insurance?
Yes
Yes
No
No
3. Have you ever been convicted of a misdemeanor?
For the purpose of this application, you have been “convicted” if you were ever found guilty by verdict of a
judge or jury; and/or ever entered a plea of guilty, nolo contendere or no contest. You must disclose all
convictions, even if the charges were later dismissed or expunged, your guilty plea was withdrawn pursuant
to Penal Code Section 1203.4, or you were placed on probation, received a suspended sentence or just
ordered to pay a fine. If you fail to disclose all convictions, your application may be denied. You may exclude
juvenile offenses tried in juvenile court.
If you answer “Yes” to this background question, you must attach to this application:
a) a written statement, with original signature, explaining the circumstances of each conviction or charge;
and,
b) certified copies of the charging documents, and of the court documents which detail the conviction,
resolution of the charges, probation and any final judgment.
Yes No
Page 3 of 6 LIC 441-9 (Rev. 01/2021)
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34. Background Information continued.
If you fail to fully disclose any information that is requested or
if you make a false statement, your application may be denied.
4. Have you ever been convicted of a military offense?
For the purpose of this application, you have been “convicted” if you were ever found guilty by verdict of a
judge or jury; and/or ever entered a plea of guilty, nolo contendere or no contest. You must disclose all
convictions, even if the charges were later dismissed or expunged, or you were placed on probation, received
a suspended sentence or just ordered to pay a fine. If you fail to disclose all convictions, your application may
be denied.
If you answer “Yes” to this background question, you must attach to this application:
a) a written statement, with original signature, explaining the circumstances of each conviction or charge; and,
b) certified copies of the charging documents, and of the court documents which detail the conviction,
resolution of the charges, probation and any final judgment.
Yes No
5. Are you currently charged with committing a crime?
“Crime” includes a felony, a misdemeanor or a military offense. You may exclude traffic citations but should
include driving offenses such as, but not limited to, reckless driving, driving under the influence and driving
with a suspended license.
If you answer “Yes” to this background question, you must attach to this application:
a) a written statement, with original signature, explaining the circumstances of each charge; and,
b) certified copies of the charging documents.
Yes No
6. Have you ever been involved in an administrative proceeding (including matters with the Department of
Insurance) regarding any professional or occupational license?
For the purpose of this application, “Involved” means having a license censured, suspended, revoked,
cancelled, terminated; or being assessed a fine, placed on probation or surrendering a license to resolve an
administrative action. “Involved” also means being named 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 denial. You may exclude terminations due
solely to noncompliance with continuing education requirements or failure to pay a renewal fee.
If you answer “Yes” to this background question, you must attach to this application:
a) a written statement, with original signature, explaining the circumstances of each disciplinary incident; and,
b) certified copies of the Notice of Hearing or other document that states the charges and allegations; and, of
the document which demonstrates the resolution of the charges or any final judgment.
Yes No
7. Has any business in which you are or were an owner, partner, officer or director ever been involved in an
administrative proceeding (including matters with the Department of Insurance) regarding any professional
or occupational license?
For the purpose of this application, “Involved” means having a license censured, suspended, revoked,
cancelled, terminated; or being assessed a fine, placed on probation or surrendering a license to resolve an
administrative action. “Involved” also means being named 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 denial. You may exclude terminations due
solely to noncompliance with continuing education requirements or failure to pay a renewal fee.
If you answer “Yes” to this background question, you must attach to this application:
a) a written statement, with original signature, explaining the circumstances of each disciplinary incident; and,
b) certified copies of the Notice of Hearing or other document that states the charges and allegations, and of
the document which demonstrates the resolution of the charges or any final judgment.
‘
Yes No
8. Has any demand been made or judgment rendered against you for any overdue monies by any insurer,
insured or producer, or have you ever been subject to a bankruptcy proceeding? (Only include
bankruptcies that involve funds held on behalf of others).
If you answer “Yes,” submit a statement, with an original signature, summarizing the details of the
indebtedness and arrangements for repayment, and/or type and location of bankruptcy.
Yes No
Page 4 of 6 LIC 441-9 (Rev. 01/2021)
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34. Background Information continued.
If you fail to fully disclose any information that is requested or
if you make a false statement, your application may be denied.
9. Have you ever been notified by any jurisdiction of any delinquent tax obligation that is not the subject of
a repayment agreement?
If you answer “Yes,” identify the jurisdiction(s):
Yes No
10. Are you currently a party to or have you 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;
b) 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
11
. Have you or any business in which you are or were an owner, partner, officer or director 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 any relevant documents.
Yes No
35. Applicant’s Certification:
By submitting this electronic application I certify that I have read the foregoing application and know the contents thereof
and that each statement therein made is full, true and correct. I understand that pursuant to sections 1668(h) and 1738
of the insurance code, any false statement may subject my application to denial and may subject my license(s) to
suspension or revocation. Further, pursuant to insurance code sections1703 and 1733, I authorize disclosure to the
insurance commissioner of all financial institution records of any fiduciary accounts for the duration of this license.
All fees are filing fees and are not refundable, whether the is acted upon or an examination taken.
Applicant’s Signature: _________________________________ City ______________ Date ___________
Page 5 of 6 LIC 441-9 (Rev. 01/2021)
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Notice: Information collection and Access
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 number: (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 of 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 purpose(s) 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
1798.34 of the Civil code.
Instructions for completing application
RE: "Applicant name" Enter full legal name. If no middle name, enter (NMN). If any part of your legal name is an initial only, place parentheses
around such initial.
RE: "Address information" Do not enter the word "same" in any address area. Enter the appropriate address. P0 Box is not acceptable for a
resident or business address. Business and mailing addresses are public record and are available to the public. It is the applicant’s/licensee’s
responsibility to immediately notify the department of any change in address.
RE: Additional "Exam information". If you fail to appear for a scheduled examination, an additional examination fee will be required for rescheduling.
RE: "AKA/Alias" List previously and currently used aliases and maiden names, if any. If you are currently using an "also known as" (AKA) name
which you desire to be noted on record, so state. Abbreviations of true name or "nick" names are not acceptable.
RE: "Background questions" If you answer yes to any of these questions, you must submit a signed statement, with your original signature
summarizing the details of each event. You must also provide the additional certified documentation described with each question.
Prelicensing Education requirements: As of January 1, 2011 all new resident applicants must:
A. take an approved minimum 20-hour class for the property broker-agent license exam, and/or;
B. take an approved minimum 20-hour class for the casualty broker-agent license exam, and/or;
C. take an approved minimum 40 hour class for property broker-agent and casualty broker-agent license examination, and/or;
D. take an approved minimum 20-hour class for the life-only agent license exam and/or;
E. take an approved minimum 20 hour class for accident and health agent license exam, and/or;
F. take an approved minimum 40 hour class for life-only and accident and health agent license examination, and/or;
G. take an approved minimum 20-hour class for the personal lines broker-agent license exam, and/or;
H. take an approved minimum 20 hour class for the limited lines automobile insurance agent license examination, and/or;
I. take an approved minimum 12-hour class on ethics and the California Insurance Code.
An applicant will be taking 32 hours (20 and 12), 52 hours (40 and 12 or 20, 20 and 12), and 72 hours (20, 40 and 12 or 20, 20, 20 and 12) of
prelicensing class hours depending on which combination of licenses are being sought.
The following documents are required to be submitted with the application for the specific license types as listed:
SL - $50,000 bond form LIC 447-31 with a properly executed Power of Attorney form attached or a Business Entity Endorsement form LIC 411-8A
completed by sponsoring Business Entity and Form LIC 050 must be completed and submitted with Surplus and/or the Special Lines’ Surplus
Broker Application.
SP - $10,000 bond form LIC 447-32 with a properly executed Power of Attorney form attached or a Business Entity Endorsement form LIC 411-8A
completed by sponsoring Business Entity and Form LIC 050 must be completed and submitted with Surplus and/or the Special Lines’ Surplus Broker
Application.
CS - $10,000 bond form LIC 447-70 with a properly executed Power of Attorney form attached.
CI - Action Notice of Appointment form LIC 447-54A from the sponsoring insurance company and/or Business Entity Endorsement form
LIC 411-8A completed by sponsoring Business Entity.
MC - Action Notice of Appointment form LIC 447-54A from the sponsoring insurance company
Forms are available on our website at www.insurance.ca.gov. To obtain insurance licensing forms by mail, send request to: Department of
Insurance, 320 Capitol Mall, Sacramento, CA 95814-4309, or you may phone Sacramento toll free at (800) 967-9331.
Mail application with attachments and fees to Department of Insurance, 320 Capitol Mall, Sacramento, CA 95814-4309.
Page 6 of 6 LIC 441-9 (Rev. 01/2021)
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Individual Application For Insurance License (California)

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Completed 8 May 2021

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