Fillable REQUEST FOR A SELF-SERVICE STORAGE PRODUCER LICENSE (Department of Technology and Information)

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REQUEST FOR A SELF-SERVICE STORAGE PRODUCER LICENSE (Department of Technology and Information)

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BROWSE DEPARTMENT OF TECHNOLOGY AND INFORMATION (DE) FORMS

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PLEASE PRINT OR TYPE
REQUEST FOR A SELF-SERVICE STORAGE PRODUCER LICENSE
Application must be completed and signed by the proprietor, a partner or an officer of the firm
APPLICATION FEE ~ $100.00 (Made payable to: Delaware Insurance Department)
CORPORATION, PARTNERSHIP, ASSOCIATION, ETC.
NAME ______________________________________________________________________________
F.E.I.N. ______________________________________________________________________________
CONTACT PERSON ____________________________________________________________________________
CONTACT PERSON PHONE #_____________________________________________________________________
CONTACT PERSON EMAIL ADDRESS _______________________________________________________________
BUSINESS ADDRESS INFORMATION
ADDRESS ___________________________________________________________________________________
SUITE OR BOX NO. ________________________________ PHONE _____________________________________
CITY _______________________________ STATE _________________ ZIP_______________________________
BUSINESS EMAIL ADDRESS ______________________________________________________________________
WEBSITE ADDRESS ____________________________________________________________________________
MAILING ADDRESS INFORMATION
ADDRESS ___________________________________________________________________________________
SUITE OR BOX NO. _________________________________ PHONE ____________________________________
CITY ______________________________ STATE ________________ ZIP ________________________________
ALTERNATE EMAIL ADDRESS ____________________________________________________________________
4B
Revised 10/18
LOCATIONS
List all locations in Delaware at which the owner plans to conduct insurance sales. Attach additional copies of
this page if necessary.
LOCATION NAME
ADDRESS
CITY
TELEPHONE
NUMBER
Please read the following very carefully and answer every question. All written
statements submitted by the Applicant must include an original signature.
1a. Has the business entity or any owner, partner, officer or director of the business entity, or member or
manager of a limited liability company, ever been convicted of a misdemeanor, had a judgment
withheld or deferred or is the business entity or any owner, partner, officer or director of the business
entity, or member or manager 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) or 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 juvenile court.)
1b. Has the business entity or any owner, partner, officer or director of the business entity, or member or
manager of a limited liability company ever been convicted of a felony, had judgment withheld or
deferred, or is the business entity or any owner, partner, officer or director of the business entity or
member or manager of a limited liability company 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. Has the business entity or any owner, partner, officer or director of the business entity or member or
manager of a limited liability company, ever been convicted of a military offense, had a judgment
withheld or deferred, or is the business entity or any owner, partner, officer or director of the business
entity or member or manager of a limited liability company, 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.
If you answer yes to any of these questions, you must attach to this application:
a) a written statement identifying all parties involved (including their percentage of ownership,
if any) and 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. Has the business entity or any owner, partner, officer or director of the business entity, or manager or
member of a limited liability company, ever 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?
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 application denied or the act of withdrawing an application to avoid a 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 any of these questions, you must attach to this application:
a.) a written statement identifying all parties involved (including their percentage of ownership, if any) and
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.
3. Has any demand been made or judgment rendered against the business entity or any owner, partner,
officer or director of the business entity, 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.
N/A__ Yes __ No __
If you answer yes, submit a statement summarizing the details of the indebtedness and arrangements for
repayment.
4. Has the business entity or any owner, partner, officer or director of the business entity, or member or
manager of a limited liability company, ever 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.
Is the business entity or any owner, partner, officer or director of the business entity, or member or
manager of a limited liability company, a party to, or 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?
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 arbitrations, or
mediation proceedings and
c) a copy of the official documents which demonstrates the resolution of the charges or any final
judgment.
6. Has the business entity or any owner, partner, officer or director of the business entity, 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 prevent you from receiving an insurance license, and
b) copies of all relevant documents.
7. 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?
N/A __ 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
On behalf of the business entity or limited liability company, the undersigned owner, partner, officer or director
of the business entity, or member or manager of a limited liability company, hereby certifies, under penalty of
perjury, that:
1. All of the information submitted in this application and attachments is true and complete and I am
aware that submitting false information or omitting pertinent or material information in connection
with this application is grounds for license or registration revocation and may subject me and the
business entity or limited liability company to civil or criminal penalties.
2. Unless provided otherwise by law or regulation of the jurisdiction , the business entity or limited
liability company hereby designates the Commissioner, Director or Superintendent of Insurance, or an
appropriate representative in each jurisdiction for which this application is made to be its agent for
service of process regarding all insurance matters in the respective jurisdiction and agree that service
upon the Commissioner or Director of that jurisdiction is of the same legal force and validity as
personal service upon the business entity.
3. The business entity or limited liability company grants permission to the Commissioner or Director of
Insurance in each jurisdiction for which this application is made to verify any information supplied
with any federal, state or local government agency, current or former employer or insurance company.
4. Every owner, partner, officer or director of the business entity, or member or manager of a limited
liability company, either a) does not have a current child-support obligation, or b) has a child-support
obligation and is currently in compliance with that obligation.
5. I authorize the jurisdictions to which this application is made to give any information they may have
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 comply with the insurance laws and regulations of the
jurisdictions to which I am applying for licensure/registration.
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).
9. I certify that the Designated Responsible Licensed Producer(s) named on this application understands
that he/she is responsible for the business entity’s compliance with the insurance laws, rules and
regulation of the State.
Must be signed by an officer, director, or partner of the business
entity, or member or manager of a limited liability company:
Signature________________________________________
Month/Day/Year _______________________________
Typed or Printed Name __________________________
Title ___________________________________________
Address _______________________________________
City State Zip___________________________________
Self-Service Storage Facility ~ Authorized Representative/Employee(s)
Below list all authorized representatives/employees that are authorized to offer insurance on behalf of the self-
service storage Producer.
LOCATION
NAME OF EMPLOYEE (S)
SSN
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REQUEST FOR A SELF-SERVICE STORAGE PRODUCER LICENSE (Department of Technology and Information)

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Completed 20 July 2020

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