Fillable VIATICAL SETTLEMENT BROKER LICENSING CHECKLIST (Department of Technology and Information)

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VIATICAL SETTLEMENT BROKER LICENSING CHECKLIST (Department of Technology and Information)

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VIATICAL SETTLEMENT BROKER LICENSING CHECKLIST
1) Application must be completed in its entirety, signed and dated.
2) A check/money order attached in the amount of $250.
3) Provide evidence of financial responsibility in either a surety bond executed and issued by an insurer authorized
to issue surety bonds in the State of Delaware or a deposit of cash, certificates of deposit or securities or any
combination thereof in the amount of $250,000.
4) Provide an anti-fraud plan that meets the requirements of Title 18, Chapter 75, 7514(g)
5) All viatical settlement contracts and disclosure statements need to be first with and approved by the
Commissioner, Title 18, Chapter 75, 7505.
1. Disclosure statements for Viatical Settlement Broker, Title 18, Chapter 75, 7508 (a) & (b)
2. Disclosure statements for Viatical Settlement Provider, Title 18, Chapter 75, 7508 (a) & (c)
APPLICANT MUST PERSONALLY COMPLETE AND SIGN THIS APPLICATION
(PLEASE PRINT OR TYPE)
REQUEST FOR VIATICAL SETTLEMENT BROKER LICENSE
Application must be completed and signed by the proprietor, a partner or an officer of the firm
NAME _______________________________________________________________________________________
F.E.I.N. ___________________________________ OR SOCIAL SECURITY #_____________________________
ADDRESS__________________________________________________ SUITE OR BOX NO.__________________
CITY_______________________STATE _________________ZIP ___________ PHONE______________________
RESIDENT EMAIL ADDRESS _____________________________________________________________________
ADDRESS _________________________________________________ SUITE OR BOX NO._________________
CITY ______________________ STATE ___________ ZIP ______________PHONE________________________
BUSINESS EMAIL ADDRESS ______________________________WEBSITE ADDRESS_____________________
ADDRESS __________________________________________________ SUITE OR BOX NO. ________________
CITY _____________________STATE _______________ ZIP ______________PHONE______________________
ALTERNATE EMAIL ADDRESS ___________________________________________________________________
BUSINESS ADDRESS INFORMATION
MAILING ADDRESS INFORMATION
3B
Revised 04/19
RESIDENT ADDRESS (INDIVIDUAL ONLY)
Below give a list of the states in which the applicant is doing business as a viatical settlement broker and indicate
whether or not the applicant is licensed in that state.
STATE
Y/N
LICENSE #
Y/N
LICENSE #
GENERAL INFORMATION
1) If the applicant is an alien company, furnish the name, address and telephone number of its American
legal counsel.
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
2) Give the name and address of the Agent for Service of Process appointed by the applicant.
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
3) Give the name and address and telephone number of the contact person or division to whom questions regarding
contract and application forms should be directed.
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
4) Give the name and address and telephone number of the contact person or division to whom questions regarding
consumer complaints should be directed. If available, provide a toll-free
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.
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:
_____________________________________
Month/Day/Year
_________________________________________
Signature
________________________________________
Typed or Printed Name
_____________________________________
Title
_____________________________________
Address
_____________________________________
City State Zip
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VIATICAL SETTLEMENT BROKER LICENSING CHECKLIST (Department of Technology and Information)

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Completed 20 July 2020

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