Draft Pending Adoption - naic.org file... Dean L. Cameron represented by Nathan Faragher (ID); ......

Draft Pending Adoption Attachment One

© 2018 National Association of Insurance Commissioners 1

Draft: 4/3/18

Producer Licensing (D) Task Force Milwaukee, Wisconsin

March 24, 2018

The Producer Licensing (D) Task Force of the Market Regulation and Consumer Affairs (D) Committee met in Milwaukee, WI, March 24, 2018. The following Task Force members participated: Barbara D. Richardson, Chair (NV); Larry Deiter, Vice Chair (SD); Lori K. Wing-Heier represented by Chris Murray (AK); Allen W. Kerr represented by Letty Hardee (AR); Dave Jones represented by Charlene Ferguson (CA); Katharine L. Wade represented by Kurt Swan (CT); David Altmaier represented by Matt Tamplin (FL); Doug Ommen represented by Andria Seip (IA); Dean L. Cameron represented by Nathan Faragher (ID); Jennifer Hammer represented by Reid McClintock (IL); Nancy G. Atkins (KY); Patrick M. McPharlin represented by Michelle Riddering (MI); Mike Chaney represented by Vanessa Miller (MS); Chlora Lindley-Myers represented by Mary Johnson (MO); Mike Causey represented by Kathy Shortt (NC); Bruce R. Ramge represented by Peg Jasa (NE); Roger A. Sevigny represented by John Elias (NH); Maria T. Vullo represented by Scott Fischer (NY); Jillian Froment represented by Whitney Fitch (OH); John D. Doak represented by Glenn Disher and Tyler Laughlin (OK); Raymond G. Farmer represented by Lee Hill (SC); Kent Sullivan represented by Jamie Walker (TX); Todd E. Kiser represented by Randal Overstreet (UT); Scott A. White represented by Van Tompkins (VA); Michael S. Pieciak represented by Kevin Gaffney (VT); Mike Kreidler represented by Jeff Baughman (WA); and Ted Nickel represented by Cari Lee (WI). 1. Adopted its 2017 Fall National Meeting Minutes Mr. Baughman made a motion, seconded by Director Deiter, to adopt the Task Force’s Dec. 2, 2017, minutes (see NAIC Proceedings – Fall 2017, Producer Licensing (D) Task Force). The motion passed unanimously. 2. Adopted Recommended Approved/Not Approved Topics for CE Credit Commissioner Richardson said the list of topics was developed to provide greater uniformity among states regarding what topics should and should not be approved for producer continuing education (CE) credit. Director Deiter made a motion, seconded by Mr. Murray, to adopt the Recommended Approved/Not Approved Topics for CE Credit. The motion passed unanimously. 3. Disbanded the Independent Adjuster Licensing (D) Working Group Commissioner Richardson recognized the work of Mr. Baughman and the efforts of the Independent Adjuster Licensing (D) Working Group. To help focus the efforts of the Task Force and support the broader efforts of the NAIC membership to streamline Working Group activities, Commissioner Richardson suggested the Adjuster Licensing (D) Working Group be disbanded and the charges of the Working Group be addressed by the Task Force, as needed. Director Deiter made a motion, seconded by Mr. Elias, to disband the Working Group and have the charges of the Working Group addressed by the Task Force, as needed. The motion passed unanimously. 4. Adopted the Report of the Producer Licensing Uniformity (D) Working Group Mr. Murray said the Working Group has been reviewing suggested revisions to the NAIC uniform applications for producers and adjusters. Mr. Murray said the Working Group solicited comments in November 2017 and will hold monthly conference calls to continue the review of suggested revisions. Wes Bissett (Independent Insurance Agents and Brokers of America—IIABA) said he is concerned with the number of suggested revisions and is concerned the Working Group will incorporate some suggested revisions based upon the preference of one state. Mr. Bissett said state insurance regulators are reviewing regulatory requirements in response to changes in technology, and much of this focus is on simplification of regulatory standards. Mr. Bissett said he hopes the Working Group remains focused on simplicity and efficiency. Commissioner Richardson agreed and requested a motion to adopt the report of the Working Group, with the appointment of Mr. Murray as chair and Karen Vourvopoulos (OH) as vice chair. Mr. Baughman made a motion, seconded by Ms. Ferguson, to adopt the report of the Working Group (Attachment One). The motion passed unanimously.

Draft Pending Adoption Attachment One

© 2018 National Association of Insurance Commissioners 2

5. Adopted the Report of the Uniform Education (D) Working Group Ms. Riddering said the Working Group will begin its review of the NAIC Continuing Education Reciprocity Agreement and Uniform Continuing Education Reciprocity Course Filing Form. Commissioner Richardson said she understands Ms. Riddering would not be able to chair the Working Group in 2018 and said Rachel Chester (RI) has agreed to chair the Working Group. Mr. Murray made a motion, seconded by Mr. Elias, to adopt the report of the Working Group (Attachment Two), with the appointment of Ms. Chester as chair. The motion passed unanimously. 6. Heard a Report from the NIPR Board of Directors Karen Stakem Hornig (National Insurance Producer Registry—NIPR) said the NIPR Board of Directors met March 23 and approved NIPR’s strategic plan, “NIPR 2020: Focused on the Future.” Over the next three years, NIPR will focus on exceptional customer service, innovation, technological excellence and stability. The Board heard a report from the NIPR Audit Committee regarding which reported NIPR revenues were 9.8% over budget and 9.8% above revenues for the prior year. NIPR released its 2017 annual report. Ms. Stakem Hornig said NIPR processed more than 29 million transactions in 2017, an all-time high. Laurie Wolf (NIPR) said each state insurance regulator on the Task Force should have a sample of NIPR’s State Dashboard in front of them. The dashboard provides an overview of the services that NIPR provides for each state or jurisdiction. Ms. Wolf said the dashboard highlights the six key technical challenges caused by the lack of uniformity that exists in the states. These areas included insurance producer license type, six major lines of authority, four core limited lines of authority, biennial birth month renewal cycle, state fee on license level and a 90-day license renewal window. Ms. Wolf said greater uniformity in these areas could improve the quality of service NIPR provides. Ms. Wolf said NIPR initially distributed the dashboards to the insurance commissioners during the 2016 Summer National Meeting and again at the 2017 Fall National Meeting. Ms. Wolf said NIPR also provided them to state producer licensing staff of each state and has been working closely with them to provide education and guidance on these six key areas.

Ms. Wolf said NIPR has made great progress on the recommended best practices, and 43 jurisdictions have agreed to adopt at least one or more of the recommended changes. For example, Ms. Wolf said more than 30 states have adopted the Producer Licensing Model Act “Insurance Producer” license class name instead of using other variations, including producer, agent, broker and insurance professional. Ms. Wolf said the work is ongoing, and NIPR plans to have further discussions about the dashboard during the NAIC/NIPR Insurance Summit in June. Ms. Wolf said each Task Force member also has in front of them maps showing which states are using NIPR products as of March 8. Ms. Wolf encouraged states to review the maps and contact NIPR about any of their products. 7. Discussed Licensing Examination Standards David Leifer (American Council of Life Insurers—ACLI) said the ACLI submitted a comment letter in February requesting the Task Force and Producer Licensing Uniformity (D) Working Group adopt criteria for states conducting annual reviews of their producer examinations. Mr. Leifer said the procedures and policies for these reviews can vary greatly from state-to-state. Commissioner Richardson agreed this is important but said the next priority for the Task Force and Working Group is business entity licensing standards. Having no further business, the Producer Licensing (D) Task Force adjourned. W:\National Meetings\2018\Spring\TF\PLTF\Minutes 3.24.18.docx

Please note the application may be revised on a bi-annual basis. To ensure you are filing the current version of the application, please reference the National Insurance Producer Registry web site at www.nipr.com.

Attachment Two

© 20149 National Association of Insurance Commissioners Page 1 of 5

Uniform Application for Individual Producer License/Registration

(Please Print or Type)

Demographic Information Soc. Security Number - -

If assigned, National Producer Number (NPN)

If applicable, FINRA Individual Central Registration Depository (CRD) Number

Last Name JR./SR. etc First Name Middle Name Date of Birth

(month) ___ (day) ___ (year)____

Residence/Home Address (Physical Street) City State Zip Code Foreign Country

Home Personal Phone Number ( ) -

Individual ApplicantPersonal Email Address:

Gender (Circle One)

Male Female

Non-Binary

Are you a Citizen of the United States? (Check One) Yes No (If No, of which country are you a citizen?) (If NO, and this is an application for a Resident License, you must supply proof of eligibility to work in the U.S.)

Employer’s Business Entity Name

Business Address (Physical Street) P.O. Box City State Zip Code Foreign Country

Business Phone Number (include extension)

( ) -

Business Fax Number ( ) -

Business E-Mail Address Business Web Site Address

Applicant’s Mailing Address

P.O. Box City State Zip Code Foreign Country

a. List any other assumed, fictitious, alias, maiden or trade names which you have used in the past. b. List any trade names under which you are currently doing business or intend to do business.

(May be subject to state approval)

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 ___________________________________________________________ FEIN ________________________ NPN ___________________ Name of Agency ___________________________________________________________ FEIN ________________________ NPN ___________________ Name of Agency ___________________________________________________________

Employment History Account for all time for the past five years. Give all employment experience starting with your current employer working back five years. Include full and part-time work, self-employment, military service, unemployment and full-time education. From To Month Year Month Year Position Held Name City State Foreign Country Name City State Foreign Country Name City State Foreign Country Name City State Foreign Country

(State Use)

7 6 5

29

1513 16

25

26 24

35

27

36

34

1 2

4

22 21 20 19 18

28 30

31 32

33

Check appropriate boxes for license requested. Resident License Non-Resident License

• Identify Home State: ___ Home State License #: _________ New Application Additional Line of Authority

3

8 9 10 11 12

17

23

http://www.nipr.com/


Attachment Two



Applicant Name: _________________________________________________

Jurisdiction and Type of License Requested Next to each jurisdiction, check the license type(s) and line(s) of authority for which you are applying. License Types:

A – Agent B – Broker P - Producer SLP – Surplus Lines Producer

Lines of Authority: V – Variable Life/Variable Annuity L – Life

H – Accident & Health or Sickness

P – Property C – Casualty PL – Personal Lines

Limited Lines: Credit– Credit CR – Car Rental CROP - Crop T – Travel

S – Surety O – Other: Specify Type

License Type Major Lines of Authority Limited Lines of Authority

Jurisdiction A B P SLP V L H P C PL Credit CR CROP T S O ___________ AK AL AR AZ CA CO CT DC DE FL GA GU HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA PR RI SC SD TN TX UT VI VA VT WA WI WV WY

37


Please note the application may be revised on a bi-annual basis. To ensure you are filing the current version of the application, please reference the National Insurance Producer Registry web site at www.nipr.com



Applicant Name: _________________________________________________

Background Questions The Applicant must read the following very carefully and answer every question. All written statements submitted by the Applicant must

include an original signature.

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.

If you answered “Yes” to any of the below questions (1a, 1b, or 1c), you must attach to this application:

a) a written statement explaining the circumstances of each incident, b) a copy of the charging documents of each incident, c) a copy of the official documents of each incident, which demonstrates the resolution of the charges or any final judgment.

1 a. Have you ever 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)

1b. Have you ever 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? (Note: For detailed information related to the requirements of 18 USC 1033 as it pertains to insurance licensing please refer to the NAIC publication “Guidelines for State Insurance Regulators to the Violent Crime Control and Law Enforcement Act of 1994” found at https://www.naic.org/documents/prod_serv_legal_sir_op.pdf)

If so, was consent granted? (Attach copy of 1033 consent approved by home state.)

Yes __ No ___ N/A___ Yes___ No____ 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?

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.

Yes __ No ___

2. Have you ever 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 or registration censured, suspended, revoked, canceled, terminated;, restricted; or, being assessed a fine, a cease and desist order, a prohibition order, a compliance order, placed on probation, sanctioned or surrendering a license or entering into a settlement 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 or any other position that exercises management or control over the business. . You may EXCLUDE terminations due solely to noncompliance with continuing education requirements or failure to pay a renewal or late filing 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. 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

38

https://www.naic.org/documents/prod_serv_legal_sir_op.pdf


Attachment Two


EVER been subject to a bankruptcy proceeding? Do not include personal bankruptcies, unless they involve funds held on behalf of others, which would include, but is not limited to, deposits, insured’s premium payments, employee tax withholdings, escrow accounts, or any monies held by you in a capacity for third parties. 3. .

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?


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 or securities broker contract or any other business relationship with an insurance company or securities business 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.

7. Do you have a child support obligation in arrearage?

If you answer yes, a) by how many months are you in arrearage? b) are you subject of a child support related subpoena/warrantyou currently subject to and in compliance with any repayment

agreement? c) are you currently subject to a repayment agreement?you the subject of a child support related subpoena/warrant? c)d) are you currently in compliance with the repayment agreement?

(If you answered yes to 7 (c), provide documentation showing proof of current payments or an approved repayment plan from the

appropriate state child support agency.)

Yes ___ No___ Yes ___ No___

Yes ___ No___ _____ Months Yes ___ No___ Yes ___ No___ N/A ___ Yes ___ No___



Attachment Two


Uniform Application for

Individual Insurance Producer License/Registration Applicant Name: _________________________________________________

8. In response to a “Yyes” answer to one or more of the Background Questions for this application, are you submitting, or have you previously submitted document(s) to the NAIC/NIPR Attachments Warehouse?

NOTE: The state(s) identified on this application will receive an alert that your supporting documents are available if: • You have previously loaded a document(s);

• You have recently submitted an application that is pending;

• You are submitting the same type of application (resident/nonresident, initial/renewal); and

• You are answering “Yes” to the same background question(s).

If you have not previously loaded your supporting documents, you may do so after you have successfully completed your application. You will be provided a link to the Attachment Warehouse instructions upon completion.

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 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.

9. Are you a member or veteran of the armed forces, or the spouse or surviving spouse of a service member or veteran?

N/A __Yes __ No__ Yes ___ No___ Yes ___ No___



Attachment Two


Uniform Application for Individual Insurance Producer License/Registration

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 and in the furtherance of the Commissioner’s, Director’s, or Superintendent’s official duties, to any federal, state or municipal agency, or any other organization and I release the jurisdictions and any person acting on behalf in the furtherance of official duties 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. The 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.

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).

7.9. I acknowledge that jurisdiction specific attachments may be required with this application. State Specific Requirements and Fees information are available at www.NIPR.com. Incomplete applications may be returned as unprocessed and considered deficient.

__________________________________________________ Month/Day/Year

_________________________________________________________________ Original Applicant Signature _________________________________________________________ Full Legal Name (Printed or Typed)

Attachments 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).

39

40



Please note the application may be revised on a bi-annual basis. To ensure you are filing the current version of the application, please reference the National Insurance Producer Registry web site at www.nipr.com. Attachment Three


Uniform Application for Individual Producer License Renewal/Continuation


Check appropriate boxes for license requested. Resident License License #: _______________ License Type: _________________ Non-Resident License License #: ____________ License Type: _________________

• Identify Home State: _____________ • Identify Home State License #: ____________

Demographic Information

National Producer Number(NPN) Date of Birth If applicable, FINRA Individual Central Registration Depository (CRD) Number:

Last Name JR./SR. etc First Name

Middle Name

Are you a Citizen of the United States? (Check One) Yes No (if No, of which country are you a citizen? _________________)

(If No, and this is an appplication for a Resident Renewal, you must supply proof of eligibility to work in the U.S.) Residence/Home Address (Physical Street)

City State Zip or Foreign Country

Individual ApplicantsPersonal Email Address:

f Personal Phone Number

Employer’s 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 ___________________________________________________________

FEIN ________________________ NPN ___________________ Name of Agency ___________________________________________________________

FEIN ________________________ NPN ___________________ Name of Agency ___________________________________________________________

Background Questions

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.


a) a written statement explaining the circumstances of each incident, b) a copy of the charging document of each incident, c) a copy of the official document of each incident, which demonstrates the resolution of the charges or any final judgment.

1a. Have you EVER been convicted of a misdemeanor, had a judgment withheld or deferred, or are you currently charged with committing a

misdemeanor, which has not been previously reported to this insurance department?

Yes ___ No___

23 24

15

1413

12

15

14

17 1816 19

26

43

25

1 2

2120 22

54

36

64

72

8 96 10

11

1 13




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)

1b. Have you EVER been convicted of a felony, had a judgment withheld or deferred, or are you currently charged with committing a felony, which has not been previously reported to this insurance department?

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? (Note: For detailed information related to the requirements of 18 USC 1033 as it pertains to insurance licensing please refer to the NAIC publication “Guidelines for State Insurance Regulators to the Violent Crime Control and Law Enforcement Act of 1994” found at https://www.naic.org/documents/prod_serv_legal_sir_op.pdf)

If so, was that consent granted? (Attach copy of 1033 consent approved by home state.)

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, which has not been previously reported to this insurance department?

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.


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 a FINRA sanction or arbitration proceeding

regarding any professional or occupational license or registration, which has not been previously reported to this insurance department? “Involved” means having a license or registration censured, suspended, revoked, canceled, terminated;, restricted or, being assessed a fine, placed

on probation, sanctioned or surrendering a license or entering into a settlement 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 or any other position that exercises management or control over the business. You may exclude EXCLUDE terminations due solely to noncompliance with continuing education requirements or failure to pay a renewal or late filing fee.


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___ N/A___ Yes___ No ___ N/A___ Yes___ No ___ Yes ___ No___ Yes ___ No___






Applicant Name: ___________________________________________

Background Questions continued

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 the subject of a child support related subpoenaff/warrant? b)c) are you currently subject to and in compliance with anya repayment agreement? c)d) are you the subject of a child support related subpoena/warrantare you currently in compliance with the repayment agreement?

(If you answered “Yes” to 3(c), provide documentation showing proof of current paymentsor an approved repayment plan from the appropriate state child support.)

4. In response to a “yYes” answer to one or more of the Background Questions for this renewal application, are you submitting, or have you previously submitted 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.

5. Are you a member or veteran of the armed forces, or the spouse or surviving spouse of a service member or veteran?

Yes __ No__

___ Months Yes __ No__ Yes __ No__

N/A __Yes __ No__

N/A __Yes __ No__ Yes ___ No___

Yes __ No__





Applicant’s Certification and Attestation The producer 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 informati

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 eac

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 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 m 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 application.

5. I authorize the jurisdictions to which this application is made to give any information concerning me, as permitted by law and in the furtherance of the Commissioner’s, Director’s municipal agency, or any other organization and I release the jurisdictions and any person acting on behalf in the furtherance of official duties their behalf from any and all liabilit

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. 7. 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 j 8. 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-res

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. 9. I acknowledge that jurisdiction specific attachments may be required with this application. State Specific Requirements and Fees information are available at www.NIPR.com. In

considered deficient.

__________________________________________________ Month/Day/Year

_________________________________________________________________ Original Producer Signature _________________________________________________________ Full Legal Name (Printed or Typed)

27



Please note the application may be revised on a bi-annual basis. To ensure you are filing the current version of the application, please reference the National Insurance Producer Registry web site at www.nipr.com. Attachment Four

© 2014 National Association of Insurance Commissioners

Page 1 of 6

Uniform Application for Business Entity License/Registration

(Please Print or Type) Check appropriate boxes for license requested.

Resident License Non-Resident License

o Identify Home State:_______________ o Identify Home State License #:_____________

New Application Additional Line(s) of Authority

(State Use)

Demographic Information Business Entity Name Incorporation/Formation Date

(month) ___(day) ___(year) _____

FEIN

- If assigned, National Producer Number (NPN) If applicable, FINRA Firm Central Registration Depository (CRD)

List any other assumed, fictitious, alias or trade names under which you are currently doing business or intend to do business.

State of Domicile Country of Domicile

Is the business entity affiliated with a financial institution/bank? Yes No

Business Address City State Zip Code Foreign Country

Phone Number (include Ext.) ( ) -

Fax Number ( ) -

Business Web Site Address Business E-Mail Address

Mailing Address P.O. Box City State Zip Code Foreign Country

Designated/Responsible Licensed Producer Identify at least one Designated/Responsible Licensed Producer responsible for the business entity’s compliance with the insurance laws, rules and regulations of this

state. (See Matrix of State Requirements at www.nipr.com for jurisdictions that require the designated/responsible licensed producer to be an officer, director or partner of the business entity.)

Name SSN - - NPN _______________________

Name SSN - - NPN________________________

Name SSN - - NPN________________________

Name SSN - - NPN________________________

Owners, Partners, Officers and Directors

Identify all owners with 10% interest or voting interest, partners, officers and directors of the business entity, or members or managers of a limited liability company:

Name Title SSN/FEIN - - D.O.B ___________Owner: Yes / No % of ownership interest ____








1

3

15 16 17 18

26

25

6 7 8

4 5

9

11 12

14 10

2

13

19 20

21 22 23 24


Please note the application may be revised on a bi-annual basis. To ensure you are filing the current version of the application, please reference the National Insurance Producer Registry web site at www.nipr.com. Attachment Four

© 2014 National Association of Insurance Commissioners

Page 2 of 6


Applicant Name: _______________________________

Jurisdiction and Type of License/Registration Requested –Major Lines of Authority Next to each jurisdiction, check the legal business type, license/registration type(s) and line(s) of authority for which you are applying.

Legal Business Type: C – Corporation P – Partnership S – Sole Proprietorship LLC – Limited Liability Company LLP – Limited Liability Partnership

License/Registration Types: A – Agent B – Broker P – Producer SLP – Surplus Lines Producer Lines of Authority: V – Variable

Life/Variable Annuity L – Life H – Accident & Health or Sickness P – Property C – Casualty P L– Personal Lines

Jurisdiction

Legal Business Type License/Registration Type Lines of Authority

C P S LLC LLP A B P SLP V L H P C PL AK AL AR AZ CA CO CT DC DE FL GA GU HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA PR RI SC SD TN TX UT VA VI VT WA WI WV WY

27




Applicant Name:______________________________________


Jurisdiction and Type of License/Registration - Limited Lines of Authority Next to each jurisdiction, check the legal business type, license/registration type(s) and line(s) of authority for which you are applying.

Legal Business Type: C – Corporation P – Partnership S – Sole Proprietorship LLC – Limited Liability Company LLP – Limited Liability Partnership

License/Registration Types : A – Agent B – Broker P – Producer SLP – Surplus Lines Producer Limited Lines: Credit – Credit CR – Car Rental CROP – Crop T – Travel S – Surety O – Other: Specify Type

Jurisdiction Legal Business Type License/Registration Type Lines of Authority

C P S LLC LLP A B P SLP Credit CR Crop T S O____________ AK AL AR AZ CA CO CT DC DE FL GA GU HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA PR RI SC SD TN TX UT VA VI VT WA WI WV WY

28




Applicant Name:______________________________________


Background Questions Please read the following very carefully and answer every question. All written statements submitted by the Applicant must include an

original signature.

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.


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 of each incident, c) a copy of the official document s of each incident, which demonstrates the resolution of the charges or any final judgment.

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 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 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? 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? (Note: For detailed information related to the requirements of 18 USC 1033 as it pertains to insurance licensing please refer to the NAIC publication “Guidelines for State Insurance Regulators to the Violent Crime Control and Law Enforcement Act of 1994” found at https://www.naic.org/documents/prod_serv_legal_sir_op.pdf) If so, was consent granted? (Attach copy of 1033 consent approved by home state.)

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 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___ N/A___ Yes____ No____ N/A___ Yes ____ No____ 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.


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 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 or registration censured, suspended, revoked, canceled, terminated, restricted; or, being assessed a fine, a cease and desist order, a prohibition order, a compliance order, placed on probation, sanctioned or surrendering a license or entering into a settlement 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 or late filing fee. If you answer yes, you must attach to this application:

a) a written statement identifying the type of license, all parties involved (including their percentage of ownership, if any) 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.

29





Applicant Name:______________________________________


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 ever been subject to a bankruptcy proceeding? Do not include personal bankruptcies, unless they involve funds held on behalf of others, which would include, but is not limited to, deposits, insured’s premium payments, employee tax withholdings, escrow accounts, or any monies held by you in a capacity for third parties..

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 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 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 ever had an insurance agency or securities broker contract or any other business relationship with an insurance company or securities business 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.

7. In response to a “Yyes” answer to one or more of the Background Questions for this application, are you submitting, or have you previously submitted document(s) to the NAIC/NIPR Attachments Warehouse?

NOTE: The state(s) identified on this application will receive an alert that your supporting documents are available if:

• You have previously loaded a document(s);





If you answer yes:


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.

Yes ___ No___ N/A___Yes ___ No___ Yes ___ No___




Applicant Name:______________________________________


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 methe business entity or any individual named in this application, as permitted by law and in the furtherance of the Commissioner’s, Director’s, or Superintendent’s official duties , to any federal, state or municipal agency, or any other organization and I release the jurisdictions and any person acting on behalf in the furtherance of official duties their behalf from any and all liability of whatever nature by reason of furnishing such information.

6. I acknowledge that I understand and that the business entity will 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 amthat the business entity is licensed and in good standing in my home state/resident state for the lines of authority requested from the non-resident state. The 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.

7.8. I hereby certify that upon request, I will furnish the jurisdiction(s) to which I am applying on behald of the business entity, 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.

10. I acknowledge that jurisdiction specific attachments may be required with this application. State Specific Requirements and Fees information are available at www.NIPR.com. Incomplete applications may be returned as unprocessed and considered deficient.

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

Attachments 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 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).

30

31



Please note the application may be revised on a bi-annual basis. To ensure you are filing the current version of the application, please reference the National Insurance Producer Registry web site at www.nipr.com. Attachment Five


Uniform Application for Business Entity License Renewal/Continuation


Check appropriate boxes for license requested. Resident License License #: _____________License Type: _____________ Non-Resident License License #: _____________ License Type: _____________

Demographic Information

Business Entity Name FEIN

-

Home State & Home State License Number If assigned, National Producer Number (NPN)

Is the business entity affiliated with a financial institution/bank? Yes No

Business Address City State Zip Code or Foreign Country

Phone Number (include extension) ( ) -

Fax Number ( ) -

Business Web Site Address Business E-Mail Address

Mailing Address P.O. Box City State Zip Code or Foreign Country

Designated/Responsible Licensed Producer Identify at least one Designated/Responsible Licensed Producer responsible for the business entity’s compliance with the insurance laws, rules and regulations of this

state. (See Matrix of State Requirements at www.nipr.com for jurisdictions that require the designated/responsible licensed producer to be an officer, director or partner of the business entity.)

Name SSN - - NPN

Name SSN - - NPN

Name SSN - - NPN

Name SSN - - NPN

7 8 9

10 11 12 13

14 15

16 17 18

19

6

5

3 4

1 2




Background Questions

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.


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 of each incident, c) a copy of the official document s of each incident, which demonstrates the resolution of the charges or any final judgment

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, or is currently charged with, committing a misdemeanor or had a judgment withheld or deferred for a misdemeanor which has not been previously reported to this insurance department?

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 ever been convicted of, or is currently charged with committing a felony or had a judgment withheld or deferred for a felony which has not been previously reported to this insurance department?

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? (Note: For detailed information related to the requirements of 18 USC 1033 as it pertains to insurance licensing please refer to the NAIC publication “Guidelines for State Insurance Regulators to the Violent Crime Control and Law Enforcement Act of 1994” found at https://www.naic.org/documents/prod_serv_legal_sir_op.pdf) If so, was consent granted? (Attach copy of 1033 consent approved by home state.)

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 ever been convicted of or is currently charged with a military offense which has not been previously reported to this insurance department?

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.


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, which has not been previously reported to this insurance department?

“Involved” means having a license or registration censured, suspended, revoked, canceled, terminated, restricted; or, being assessed a fine, placed on probation, sanctioned or surrendering a license or entering into a settlement 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. “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 or late filing fee. If you answer yes, you must attach to this application:

a) a written statement identifying the type of license; identifying all parties involved (including their percentage of ownership, if any) 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___ Yes ___ No___ N/A___ Yes____ No____ N/A ___ Yes ___ No ___ Yes ___ No___

20





Uniform Application for Business Entity License Renewal/Continuation

Applicant Name: ___________________________________

Background Questions continued 3. In response to a “Yyes” answer to one or more of the Background Questions for this renewal application, are you submitting, or have

you previously submitted document(s) to the NAIC/NIPR Attachments Warehouse?






If you answer yes;


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.

N/A___Yes ___ No___ Yes ___ No___




Uniform Application for

Business Entity License Renewal/Continuation

Applicant Name: ___________________________________

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 the business entity or any individual named in this applicationme, as permitted by law and in the furtherance of the Commissioner’s, Director’s, or Superintendent’s official duties, to any federal, state or municipal agency, or any other organization and I release the jurisdictions and any person acting on behalf in the furtherance of official duties their behalf from any and all liability of whatever nature by reason of furnishing such information.

6. I acknowledge that I understand and that the business entity will 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 amthe business entity is licensed and in good standing in my home state/resident state for the lines of authority requested from the non-resident state. The 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.

8. I hereby certify that upon request, I will furnish the jurisdiction(s) to which I am applying, on behalf of the business entity, 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.

10. I acknowledge that jurisdiction specific attachments may be required with this application. State Specific Requirements and Fees information are available at www.NIPR.com. Incomplete applications may be returned as unprocessed and considered deficient.

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

21



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Documents

Transcript of Draft Pending Adoption - naic.org file... Dean L. Cameron represented by Nathan Faragher (ID); ......