Fill - Free fillable Individual Renewal NAIC Uniform Application for (Arizona) PDF form

Page 1 of 3 INSTRUCTIONS for NAIC renewal application

INSTRUCTIONS

NAIC Uniform Application for

Individual Renewal

LICENSING

FOR USE IN APPLYING FOR AN INITIAL INSURANCE LICENSE OR ADDING A LINE OF AUTHORITY FOR AN INDIVIDUAL.

USE THE NATIONAL INSURANCE PRODUCER REGISTRY (

www.nipr.com

) instead of a

paper application form to renew a license online. NIPR applications are processed more quickly.

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

PRODUCERS page of the Department of Insurance web site for instructions on how to apply for

new license authority.

 To apply to renew the license of a business entity. Use www.nipr.com instead.

Carefully read 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.

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, ARIZONA DEPARTMENT OF INSURANCE,

100 NORTH 15

AVENUE, SUITE 102, PHOENIX, AZ 85007-2624

QUESTIONS? Before calling the Department of Insurance, look for answers on the PRODUCERS

page of the Department of Insurance Internet web site (https://insurance.az.gov/). For questions

not addressed on our web site, contact the Insurance Licensing Section:

 E-mail: Licensing@azinsurance.gov

 Phone: 602-364-4457, or 877-660-0964 if calling long-distance within Arizona.

LICENSE CERTIFICATES. The Department does not print license certificates. View your license using the

License Search option on the Department’s web site (https://insurance.az.gov/).

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 shall 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 need to submit an application for a new license and you will

need to

ill all o

uirements

or obtainin

a new license.

Page 2 of 3 INSTRUCTIONS for NAIC renewal application

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 field is not required to be completed. 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.

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.

Page 3 of 3 INSTRUCTIONS for NAIC renewal application

CONTINUING EDUCATION

Continuing education (“CE”) requirements applicable to Arizona-resident insurance producers have changed.

Please visit the PRODUCERS CE page of our web site (https://insurance.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 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.

1. FEES :

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

One fee 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

Mexican Insurance Surplus Lines Broker

$1000.00

Life Settlement Broker License Fee ..........  $500.00

Navigator and/or Certified Application

Counselor .................................................... 

$0.00

Late Fee .......................................................  $100.00

One fee per License Class/Type requested.

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 #:

Demo

raphic Information

Soc. Security Number

_ _

Date of Birth

If assigned National Producer

Number (NP#)

Last Name JR./SR. etc

First Name

Residence/Home Address (Physical Street)

Individual Applicants Email Address:

City

State

Zip or Foreign Country

Business Entity’s Name

Business Address (Physical Street)

P.O. Box

City

State

Zip or Foreign Country

Business Phone Number (include

extension)

( ) -

Business Fax Number

( ) -

Business E-Mail Address

Business Web Site Address

Mailing Address

P.O. Box

City

State

Zip or Foreign

Country

Agency or Business Entity Affiliations

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

Back

round Information

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

Uniform Application for

Individual Producer License Renewal/Continuation

Back

round 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

N/A

Yes No

Uniform Application for

Individual Producer License Renewal/Continuation

Applicant’s Certification and Attestation

The producer must read the following very carefully:

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.

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.

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.

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.

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.

I acknowledge that I understand and will comply with the insurance laws and regulations of the jurisdictions to which I am applying for licensure.

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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