Fillable REQUEST FOR A DELAWARE INSURANCE LICENSE (Department of Technology and Information)

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REQUEST FOR A DELAWARE INSURANCE LICENSE (Department of Technology and Information)

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PLEASE PRINT OR TYPE
REQUEST FOR A DELAWARE INSURANCE LICENSE
PART 1 LICENSE IDENTIFICATION
If No, you must supply eligibility of proof to work in the U.S.
Are
you applying for a Delaware Resident License? (Check One) Yes No
If no, please provide your Resident state ______________________________________
ADDRESS________________________________________________________ SUITE OR BOX NO. _________________
CITY________________________________STATE ______________________ ZIP______________________________
PHONE _________________________________ EMAIL ADDRESS ___________________________________________
EMPLOYER’S NAME_________________________________________________________________________________
ADDRESS ________________________________________________________SUITE OR BOX NO.__________________
CITY___________________STATE __________ ZIP _____________________ PHONE ____________________________
BUSINESS EMAIL ADDRESS _______________________________ WEBSITE ADDRESS ____________________________
ADDRESS_______________________________________________________ SUITE OR BOX NO. ___________________
CITY _______________________________STATE ________________________ZIP ______________________________
EMAIL ADDRESS ____________________________________________________________________________________
2A
REVISED 07/17
RESIDENT ADDRESS INFORMATION
BUSINESS ADDRESS INFORMATION
MAILING ADDRESS INFORMATION
NAME _____________________________________________________________________________________
SOC. SEC. NO. ____________________ BIRTH DATE _________________ GENDER Male Female
Are you a Citizen of the United States? (Check One) Yes No
If No, of which country are you a citizen? _____________________________
PART 2 TYPE OF LICENSE REQUESTED
If
applying for an Adjuster License, what is your DHS (Designated Home State)? _________________________
PART 3 LINES OF AUTHORITY
If applying for Variable Annuity, please provide your FINRA Individual Central Registration Depository (CRD)
______________________________________
PRODUCER
$100
APPRAISER
$100
LIMITED LINES PRODUCER
$100
ADJUSTER
$100
APPRENTICE APPRAISER
$50
$100
APPRENTICE ADJUSTER
$50
SURPLUS LINES BROKER
$250
$200
PUBLIC ADJUSTER
$100
FRATERNAL PRODUCER
$100
$1000
(1)LIFE
(8)VARIABLE ANNUITY
(15)BAIL AGENT
(2)HEALTH
(9)MOTOR VEHICLE
(16)PROPERTY BAIL AGENT
(4)PROPERTY
(10)CREDIT
(23)CROP/HAIL
(5)CASUALTY
(11)TRAVEL
(24)AUTOMOBILE CLUB
(6)SURETY
(13)MARINE TRANSPORTATION
(27)WORKERS’ COMPENSATION
(7)TITLE
(14)PERSONAL LINES
The Applicant must read the following very carefully and answer every question. All written statements
submitted by the Applicant must include an original signature.
1
a. Have you ever been convicted of a misdemeanor, had a judgment withheld or deferred, or are you currently charged with
committing a misdemeanor?
Yes ___ No___
You may exclude the following misdemeanor convictions or pending misdemeanor charges: traffic citations, driving under the
influence (DUI), driving while intoxicated (DWI), driving without a license, reckless driving, or driving with a suspended or revoked
license. You may also exclude juvenile adjudications (offenses where you were adjudicated delinquent in a juvenile court)
1
b. Have you ever been convicted of a felony, had a judgment withheld or deferred, or are you currently charged with committing
a felony?
Yes __ No ___
You may exclude juvenile adjudications (offenses where you were adjudicated delinquent in a juvenile court)
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 consent granted? (Attach copy of 1033 consent approved by home state.) N/A___ Yes___ No____
1c
. Have you ever been convicted of a military offense, had a judgment withheld or deferred, or are you currently charged with
committing a military offense?
Yes __ No ___
NOTE:
For Questions 1a, 1b and 1c, “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.
I
f you answer yes to any of these questions, 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.
2
. Have you ever been named or involved as a party in an administrative proceeding, including FINRA sanction or arbitration
proceeding regarding any professional or occupational license or registration?
Yes ___ No___
“Involved” means having a license censured, suspended, revoked, canceled, terminated; or, being assessed a fine, a cease and
desist order, a prohibition order, a compliance order, 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.
I
f 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
. Has any demand been made or judgment rendered against you or any business in which you are or were an owner, partner, officer
or director, or member or manager of a limited liability company, for overdue monies by an insurer, insured or producer, or have you
ever been subject to a bankruptcy proceeding? Do not include personal bankruptcies, unless they involve funds held on behalf of
others.
Yes ___ No___
If you answer yes, submit a statement summarizing the details of the indebtedness and arrangements for repayment, and/or type
and location of bankruptcy.
4. Have you been notified by any jurisdiction to which you are applying of any delinquent tax obligation that is not the subject of a
repayment agreement?
Yes ___ No___
If you answer yes, identify the jurisdiction(s): _______________________________________
5. Are you currently a party to, or have you ever been found liable in, any lawsuit, arbitrations or mediation proceeding involving
allegations of fraud, misappropriation or conversion of funds, misrepresentation or breach of fiduciary duty?
Yes ___ No___
If you answer yes, you must attach to this application:
a) a written statement summarizing the details of each incident,
b) a copy of the Petition, Complaint or other document that commenced the lawsuit or arbitration, or
mediation proceedings, and
c) a copy of the official documents, which demonstrates the resolution of the charges or any final judgment.
6. Have you or any business in which you are or were an owner, partner, officer or director, or member or manager of a limited
liability company, ever had an insurance agency contract or any other business relationship with an insurance company terminated
for any alleged misconduct?
Yes ___ No___
If you answer yes, you must attach to this application:
a) a written statement summarizing the details of each incident and explaining why you feel this incident should not
b) prevent you from receiving an insurance license, and
c) copies of all relevant documents
7. Do you have a child support obligation in arrearage? Yes ___ No___
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?
(If you answered yes, provide documentation showing proof of current payments or an approved repayment plan
from the appropriate state child support agency.)
8. In response to a “yes” answer to one or more of the Background Questions for this application, are you submitting document(s) to
the NAIC/NIPR Attachments Warehouse?
Yes ___ No___
If you answer yes
Will you be associating (linking) previously filed documents from the NAIC/NIPR Attachments Warehouse to this application?
Yes ___ No___
Note: If you have previously submitted documents to the Attachments Warehouse that are intended to be filed with this 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.
Applicant’s Certification and Attestation
The Applicant 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. For Non-Resident License Applications, I certify that I am licensed and in good standing in my home state/resident state for the lines
of authority requested from the non-resident state.
8. 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 Applicant Signature
__________________________________________________
Full Legal Name (Printed or Typed)
The following attachments must accompany the application otherwise the application may be returned unprocessed or considered deficient.
1. For Non-Resident License Applications and unless otherwise noted in the State Matrix of Business Rules, a state will rely on an electronic
verification of an Applicant’s resident license through the NAIC’s State Producer Licensing Database in lieu of requiring an original Letter of
Certification from the resident state.
2. Any jurisdiction specific attachments listed in the State Matrix of Business Rules (www.nipr.com).
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REQUEST FOR A DELAWARE INSURANCE LICENSE (Department of Technology and Information)

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Completed 20 July 2020

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