Form L-PRV (Rev. 04/2020)
Page 2 of 3
SECTION V: BACKGROUND QUESTIONS
Read the following very carefully and answer every question. All written statements that you submitted must include an original signature.
1a. Have you ever been convicted of a misdemeanor, had a judgment withheld or deferred, or are you currently charged with committing a
misdemeanor?
You may exclude misdemeanor convictions or pending misdemeanor charges that are related to operating a vehicle.
You may exclude juvenile adjudications (offenses where you were adjudicated delinquent in a juvenile court)
Yes No
1b. Have you ever been convicted of a felony, had a judgment withheld or deferred, or are you currently charged with committing a felony?
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?
Not applicable Yes No
If so, was consent granted? (Attach copy of 1033 consent approved by home state.)
Not applicable 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. If 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?
“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.
being named as a party to an administrative or arbitration proceeding, which is related to a professional or occupational license, or
registration.
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.
Yes No
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.
If you answer yes, submit a statement summarizing the details of the indebtedness and arrangements for repayment, and/or type and
location of bankruptcy.
Yes No
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? If you answer yes, identify the jurisdiction(s) below:
____________________________________________________________________________________________________________
Yes No
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? 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.
Yes No
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? 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.
Yes No
7. Do you have a child support obligation in arrears? If you answer yes, provide documentation showing proof of current payments or an
approved repayment plan from the appropriate state child support agency and respond to the following questions:
a) By how many months are you in arrears?
_________________
b) Are you currently subject to and in compliance with any repayment agreement?
Yes No
c) Are you the subject of a child support related subpoena/warrant?
Yes No
Yes No
