Application Insurance License PDF Details

Embarking on a career in the insurance industry in California involves navigating through the detailed process outlined by the State of California Department of Insurance's Individual Application For Insurance License, known as the LIC-441-9 form, revised in January 2021. This comprehensive document serves multiple critical functions, essential for both first-time applicants and existing license holders looking to renew or expand their credentials. It starts with specifying the application type, distinguishing between permanent applications and certificates of convenience, catering to a wide range of insurance fields such as life, health, property, casualty, and more specialized areas like motor club, personal lines, and surplus line brokerage. The form demands personal and professional details, including legal names, gender, contact information, residency, citizenship status, and affiliations with financial institutions. Moreover, it delves into the applicant's work and personal history over the last five years, seeking exhaustive employment records, including periods of self-employment, unemployment, and full-time education. One of the form's crucial aspects is its rigorous background information section, designed to uphold the industry's integrity, asking for disclosures on any convictions, administrative proceedings, or financial delinquencies that might affect the applicant's eligibility. Completing this form accurately is pivotal as it requires attestation to the truthfulness of the provided information, understanding that any false statement could lead to the application's denial or future license revocation, thereby setting the foundation for a career built on trust and compliance in the insurance domain.

QuestionAnswer
Form NameApplication Insurance License
Form Length6 pages
Fillable?No
Fillable fields0
Avg. time to fill out1 min 30 sec
Other namesapplication naic form, application producer, naic uniform insurance, insurance license application

Form Preview Example

State of California

 

 

 

 

 

 

 

 

 

Department of Insurance

Individual Application For Insurance License

 

 

 

 

 

 

 

 

 

 

 

 

LIC-441-9 (Rev 01/2021)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

1.

Application Type: □ Permanent □ Certificate of Convenience

 

 

For Department Use Only

2.

 

License Type:

 

 

 

□ Part Time Fraternal Agent (PF)

 

License #

 

 

□

Accident & Health or Sickness (AH)

 

 

 

 

 

 

 

 

 

 

 

Life Agent (LO)

 

 

 

□ Portable Electronics Agent (PE)

 

 

 

 

 

 

 

 

□

 

 

 

 

 

 

 

 

 

 

 

Variable Life and Variable Annuity (VC)

□ Car Rental Agent (RC)

 

 

 

 

 

 

 

 

□

 

 

 

 

 

 

 

 

 

 

 

 

Surplus Line Broker (SL)*

 

 

 

 

 

 

 

 

□ Property Broker-Agent (PR)

 

 

□ Special Lines’ Surplus Line Broker (SP)*

 

 

 

 

 

 

 

 

 

 

Life & Disability Analyst (LA)

□ Casualty Broker-Agent (CA)

 

 

□ Self-Service Storage Agent (SS)

 

 

□Motor Club Agent (MC)

□ Personal Lines Broker-Agent (PL)

□ Title Marketing (TM)

 

 

□Cargo Shipper’s Agent (CS)

□ Limited Lines Auto Insurance Agent (AU)

□ Burial and Funeral Expenses (LOLP)

 

 

□ Vehicle Service Contract

□ Credit Insurance Agent (CI)

 

 

□

 

 

 

 

 

 

□ Provider (VS)

3.

Last Name

 

 

 

First Name

 

Middle Name

 

 

Suffix

 

 

 

 

 

 

 

 

 

 

 

 

 

4.

□ Male □ Female

5.

Birthdate (MM/DD/YYYY)

 

6. Social Security Number or Individual Tax Identification Number**

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

7.

Resident Address (P.O. Box not acceptable)

 

 

 

8. City

 

 

9.

State

10. Zip Code

 

 

 

 

 

 

 

 

 

 

I

 

 

 

I

 

 

I

11. Home Phone Number

12.

 

Are you a citizen of the United States? □ Yes □ No

13. Are you affiliated with a

 

 

 

financial institution/bank?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

□ Yes

□ No

 

 

14.

Business Address (P.O.

Box not acceptable.)

 

 

 

15. City

 

 

 

16. State

17. Zip Code

 

 

 

 

 

 

 

 

 

 

1

 

 

 

I

 

 

I

18.

Business Phone Number

 

19. Business Fax Number

 

I

20. E-mail

Address (required)

 

 

21.

Business Web Site Address

 

 

 

I

 

 

 

 

 

 

 

 

 

 

 

 

 

22.

Mailing Address (P.O. Box

is acceptable.)

 

 

 

 

 

23. City

 

 

 

24. State

25. Zip Code

 

 

 

 

 

 

 

 

 

 

1

 

 

 

I

 

 

I

26. Special Accommodation Request for Examination - If required, arrangements were made prior to taking and passing the license examination.

27. Examination Information: If required, you must first pass your license examination before submitting this license application. After you pass your license examination, please ensure that all required documents are submitted. If you are required to submit documents, please email them to: CADepartmentofInsuranceLicensingExams@insurance.ca.gov or send them to: CA Dept. of Insurance, Attention: Individual License Application, 320 Capitol Mall, Sacramento, CA 95814-4309

*Form LIC 050 must be completed and submitted with Surplus and/or the Special Lines’ Surplus Broker Application.

**Disclosure of your U.S. social security number or an individual tax identification number issued by the Internal Revenue Service pursuant to Cal. Insurance Code, §1666.5(a)(2) is mandatory pursuant to; Cal. Family Code, § 17520(d); the Federal Tax Reform Act of 1976 (42 U.S.C. §405(c)(2)(C)(i)) and the Federal Welfare Reform Act of 1996 (42 U.S.C. §666). If you fail to disclose your social security number or your individual tax identification number, your application will not be reviewed. An individual has a right of access to certain records containing personal information pertaining to that individual. Individuals may obtain information regarding the location of their records by contacting the Bureau Chief, Producer Licensing Bureau, California Department of Insurance by telephone (800-967-9331) or by mail to the following address: 320 Capitol Mall, Sacramento CA 95814.

28.Work/Personal History: Account for all time for the past five years. Give all employment experiences starting with your current employer working back five years. Include full and part-time work, self-employment, military service, unemployment, and full-time education. Attach separate sheet, if needed.

 

 

From

To

Position Held

 

 

Month Year

Month Year

 

 

 

Name

 

 

I

 

I

 

 

 

 

 

 

City

State

 

 

 

 

 

 

 

 

 

 

 

 

Name

 

 

I

 

I

 

 

 

 

 

 

City

State

 

 

 

 

 

 

 

 

 

 

 

 

Name

 

 

I

 

I

 

 

 

 

 

 

City

State

 

 

 

 

 

 

 

 

 

 

 

 

Name

 

 

I

 

I

 

 

 

 

 

 

City

State

 

 

 

 

 

 

 

 

 

 

 

 

29. Do you now hold, or have you ever held, an insurance license as a resident in this state or any other state?

Type of License

 

State or Province

 

Date License Held

□ Yes □ No

 

 

Is License in Force?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

30.AKA/Alias

Are you now using or have you ever used any name other than shown? □ Yes □ No

If yes, list names, dates and reason(s) used:

Last

First

Middle

Suffix

Dates Used

Reason Used

Last

First

Middle

Suffix

Dates Used

Reason Used

31. Fictitious Names:

Do you intend to use a fictitious (DBA) name?

If yes, list the name: (This name must be approved by the Department prior to use) □ Yes □ No

32.Life-Only Agent/Part Time Fraternal License Applicants Only:

Are you registered with the Securities and Exchange Commission (SEC) or Financial Industry Regulatory Authority (FINRA)?

 

□ Yes □ No

Central Registration Depository Number (CRD)

If CRD# is not provided, acceptable proof of registration

must be attached before the authority may be granted. If acceptable proof is not submitted, license will be issued without variable life and variable annuity authority.

33.Prelicensing Certificates:

Do you certify that you have completed your prelicensing education? □ Yes □ No

If no, your prelicensing education must be completed prior to taking your examination.

If yes, you must provide the completion date:

Page 2 of 6

LIC 441-9 ( 01/2021)

34.

Background Information

 

 

If you fail to fully disclose any information that is requested or

 

 

if you make a false statement, your application may be denied.

 

 

 

 

1.

Have you ever been convicted of a felony?

□ Yes □ No

For the purpose of this application, you have been “convicted” if you were ever found guilty by verdict of a

 

judge or jury; and/or ever entered a plea of guilty, nolo contendere or no contest. You must disclose all

 

convictions, even if the charges were later dismissed or expunged, your guilty plea was withdrawn pursuant

 

to Penal Code Section 1203.4, or you were placed on probation, received a suspended sentence or just

 

ordered to pay a fine. If you fail to disclose all convictions, your application may be denied. You may exclude

 

juvenile offenses tried in juvenile court.

 

If you answer “Yes” to this background question, you must attach to this application:

 

a) a written statement, with original signature, explaining the circumstances of each conviction or charge;

 

and,

 

b) certified copies of the charging documents, and of the court documents which detail the conviction,

 

resolution of the charges, probation and any final judgment.

 

 

 

2. Federal law (18 U.S.C. 1033) prohibits anyone who has been convicted of a felony involving dishonesty or

 

a breach of trust or who has been convicted of any violation of 18 U.S.C. 1033 and 1034 from engaging in the

 

business of insurance unless they have obtained the written consent of the Insurance Commissioner. It is a

 

violation of this statute to engage in the business of insurance without the Commissioner’s written consent. If

 

you have been convicted of a felony involving dishonesty or a breach of trust or a violation of 18 U.S.C. 1033

 

and 1034, then you must attach a copy of this consent. If you have not obtained this written consent, you

 

must do so prior to filing your application.

 

a. Have you ever been convicted of a felony involving dishonesty or a breach of trust?

□ Yes □ No

For the purpose of this application, you have been “convicted” if you were ever found guilty by verdict of a

 

judge or jury; and/or ever entered a plea of guilty, nolo contendere or no contest. You must disclose all

 

convictions, even if the charges were later dismissed or expunged, your guilty plea was withdrawn pursuant

 

to Penal Code Section 1203.4, or you were placed on probation, received a suspended sentence or just

 

ordered to pay a fine. If you fail to disclose all convictions, your application may be denied. You may exclude

 

juvenile offenses tried in juvenile court.

 

If you answered “Yes” to background question 2a, you must attach to this application:

 

i. a written statement, with original signature, explaining the circumstances of each conviction or charge; and,

 

ii. certified copies of the charging documents, and of the court documents which detail the conviction,

 

resolution of the charges, probation and any final judgment.

 

b.

If you have been convicted of a felony involving dishonesty or a breach of trust, have you received written

□ Yes □ No

 

consent from the California Insurance Commissioner to engage in the business of insurance?

 

3.

Have you ever been convicted of a misdemeanor?

□ Yes □ No

For the purpose of this application, you have been “convicted” if you were ever found guilty by verdict of a

 

judge or jury; and/or ever entered a plea of guilty, nolo contendere or no contest. You must disclose all

 

convictions, even if the charges were later dismissed or expunged, your guilty plea was withdrawn pursuant

 

to Penal Code Section 1203.4, or you were placed on probation, received a suspended sentence or just

 

ordered to pay a fine. If you fail to disclose all convictions, your application may be denied. You may exclude

 

juvenile offenses tried in juvenile court.

 

If you answer “Yes” to this background question, you must attach to this application:

 

a)

a written statement, with original signature, explaining the circumstances of each conviction or charge;

 

 

and,

 

b) certified copies of the charging documents, and of the court documents which detail the conviction,

 

 

resolution of the charges, probation and any final judgment.

 

 

 

 

Page 3 of 6

LIC 441-9 (Rev. 01/2021)

34. Background Information continued.

If you fail to fully disclose any information that is requested or if you make a false statement, your application may be denied.

4. Have you ever been convicted of a military offense?

□ Yes □ No

For the purpose of this application, you have been “convicted” if you were ever found guilty by verdict of a

 

judge or jury; and/or ever entered a plea of guilty, nolo contendere or no contest. You must disclose all

 

convictions, even if the charges were later dismissed or expunged, or you were placed on probation, received

 

a suspended sentence or just ordered to pay a fine. If you fail to disclose all convictions, your application may

 

be denied.

 

If you answer “Yes” to this background question, you must attach to this application:

 

a) a written statement, with original signature, explaining the circumstances of each conviction or charge; and,

 

b) certified copies of the charging documents, and of the court documents which detail the conviction,

 

resolution of the charges, probation and any final judgment.

 

 

 

5. Are you currently charged with committing a crime?

□ Yes □ No

“Crime” includes a felony, a misdemeanor or a military offense. You may exclude traffic citations but should

 

include driving offenses such as, but not limited to, reckless driving, driving under the influence and driving

 

with a suspended license.

 

If you answer “Yes” to this background question, you must attach to this application:

 

a) a written statement, with original signature, explaining the circumstances of each charge; and,

 

b) certified copies of the charging documents.

 

 

 

6. Have you ever been involved in an administrative proceeding (including matters with the Department of

□ Yes □ No

Insurance) regarding any professional or occupational license?

For the purpose of this application, “Involved” means having a license censured, suspended, revoked,

 

cancelled, terminated; or being assessed a fine, placed on probation or surrendering a license to resolve an

 

administrative action. “Involved” also means being named 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 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 this background question, you must attach to this application:

 

a) a written statement, with original signature, explaining the circumstances of each disciplinary incident; and,

 

b) certified copies of the Notice of Hearing or other document that states the charges and allegations; and, of

 

the document which demonstrates the resolution of the charges or any final judgment.

 

 

 

7. Has any business in which you are or were an owner, partner, officer or director ever been involved in an

 

administrative proceeding (including matters with the Department of Insurance) regarding any professional

□ Yes □ No

or occupational license?

For the purpose of this application, “Involved” means having a license censured, suspended, revoked,

 

cancelled, terminated; or being assessed a fine, placed on probation or surrendering a license to resolve an

 

administrative action. “Involved” also means being named 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 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 this background question, you must attach to this application:

 

a) a written statement, with original signature, explaining the circumstances of each disciplinary incident; and,

 

b) certified copies of the Notice of Hearing or other document that states the charges and allegations, and of

 

the document which demonstrates the resolution of the charges or any final judgment. ‘

 

 

 

8. Has any demand been made or judgment rendered against you for any overdue monies by any insurer,

 

insured or producer, or have you ever been subject to a bankruptcy proceeding? (Only include

□ Yes □ No

bankruptcies that involve funds held on behalf of others).

If you answer “Yes,” submit a statement, with an original signature, summarizing the details of the

 

indebtedness and arrangements for repayment, and/or type and location of bankruptcy.

 

 

 

8 Page 4 of 6

LIC 441-9 (Rev. 01/2021)

34.Background Information continued.

If you fail to fully disclose any information that is requested or if you make a false statement, your application may be denied.

9. Have you ever been notified by any jurisdiction of any delinquent tax obligation that is not the subject of

□ Yes □ No

 

a repayment agreement?

If you answer “Yes,” identify the jurisdiction(s):

 

 

 

 

 

10. Are you currently a party to or have you ever been found liable in any lawsuit or arbitration proceeding

 

 

involving allegations of fraud, misappropriation or conversion of funds, misrepresentation or breach of

□ Yes □ No

 

fiduciary duty?

If you answer “Yes,” you must attach to this application:

 

a)

a written statement, with original signature, summarizing the details of each incident;

 

b)

copy of the Petition, Complaint, or other document that commenced the lawsuit or arbitration; and

 

c)

a copy of the official document which demonstrates the resolution of the charges or any final judgment.

 

 

 

11. Have you or any business in which you are or were an owner, partner, officer or director ever had an

 

 

insurance agency contract or any other business relationship with an insurance company terminated

□ Yes □ No

 

for any alleged misconduct?

If you answer “Yes,” you must attach to this application:

 

a) a written statement, with original signature, 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 any relevant documents.

 

 

 

35. Applicant’s Certification:

 

By submitting this electronic application I certify that I have read the foregoing application and know the contents thereof and that each statement therein made is full, true and correct. I understand that pursuant to sections 1668(h) and 1738 of the insurance code, any false statement may subject my application to denial and may subject my license(s) to suspension or revocation. Further, pursuant to insurance code sections1703 and 1733, I authorize disclosure to the insurance commissioner of all financial institution records of any fiduciary accounts for the duration of this license.

All fees are filing fees and are not refundable, whether the is acted upon or an examination taken.

Applicant’s Signature: _________________________________ City ______________ Date ___________

Page 5 of 6

LIC 441-9 (Rev. 01/2021)

Notice: Information collection and Access

Section 1798.17 of the California Civil Code requires the following information to be provided when collecting information from individuals to determine compliance with the group and corporate practice provisions of the law, and to establish positive identification, to match the names of the certified list provided by the Department of Child Support Services to applicants and licensees, and of responding to requests for this information made by child support agencies.

Agency: Department of Insurance, Address: 320 Capitol Mall, Sacramento, CA 95814-4309, Telephone number: (800) 967-9331.

Title of official responsible for information maintenance: Chief, Producer Licensing Bureau.

Authority which authorizes the maintenance of the information: California Insurance Code, Chapters 5, 6, 7, 8-Part 2, Division 1.

The consequences, if any, of not providing all of part of the requested information: It is mandatory that you provide all information requested. Omission of any item of requested information will result in the application being rejected as incomplete.

The principal purpose(s) for which the information is to be used: The information requested will be used to determine qualifications for licensure or certification, to determine compliance with the group and corporate practice provisions of the law and to establish positive identification.

Each individual has the right to review files maintained on them by the agency, unless the information is classified as confidential under section 1798.34 of the Civil code.

Instructions for completing application

RE: "Applicant name" Enter full legal name. If no middle name, enter (NMN). If any part of your legal name is an initial only, place parentheses around such initial.

RE: "Address information" Do not enter the word "same" in any address area. Enter the appropriate address. P0 Box is not acceptable for a resident or business address. Business and mailing addresses are public record and are available to the public. It is the applicant’s/licensee’s responsibility to immediately notify the department of any change in address.

RE: Additional "Exam information". If you fail to appear for a scheduled examination, an additional examination fee will be required for rescheduling.

RE: "AKA/Alias" List previously and currently used aliases and maiden names, if any. If you are currently using an "also known as" (AKA) name which you desire to be noted on record, so state. Abbreviations of true name or "nick" names are not acceptable.

RE: "Background questions" If you answer yes to any of these questions, you must submit a signed statement, with your original signature summarizing the details of each event. You must also provide the additional certified documentation described with each question.

Prelicensing Education requirements: As of January 1, 2011 all new resident applicants must:

A.take an approved minimum 20-hour class for the property broker-agent license exam, and/or;

B.take an approved minimum 20-hour class for the casualty broker-agent license exam, and/or;

C.take an approved minimum 40 hour class for property broker-agent and casualty broker-agent license examination, and/or;

D.take an approved minimum 20-hour class for the life-only agent license exam and/or;

E.take an approved minimum 20 hour class for accident and health agent license exam, and/or;

F.take an approved minimum 40 hour class for life-only and accident and health agent license examination, and/or;

G.take an approved minimum 20-hour class for the personal lines broker-agent license exam, and/or;

H.take an approved minimum 20 hour class for the limited lines automobile insurance agent license examination, and/or;

I.take an approved minimum 12-hour class on ethics and the California Insurance Code.

An applicant will be taking 32 hours (20 and 12), 52 hours (40 and 12 or 20, 20 and 12), and 72 hours (20, 40 and 12 or 20, 20, 20 and 12) of prelicensing class hours depending on which combination of licenses are being sought.

The following documents are required to be submitted with the application for the specific license types as listed:

SL - $50,000 bond form LIC 447-31 with a properly executed Power of Attorney form attached or a Business Entity Endorsement form LIC 411-8A completed by sponsoring Business Entity and Form LIC 050 must be completed and submitted with Surplus and/or the Special Lines’ Surplus Broker Application.

SP - $10,000 bond form LIC 447-32 with a properly executed Power of Attorney form attached or a Business Entity Endorsement form LIC 411-8A completed by sponsoring Business Entity and Form LIC 050 must be completed and submitted with Surplus and/or the Special Lines’ Surplus Broker Application.

CS - $10,000 bond form LIC 447-70 with a properly executed Power of Attorney form attached.

CI - Action Notice of Appointment form LIC 447-54A from the sponsoring insurance company and/or Business Entity Endorsement form LIC 411-8A completed by sponsoring Business Entity.

MC - Action Notice of Appointment form LIC 447-54A from the sponsoring insurance company

Forms are available on our website at www.insurance.ca.gov. To obtain insurance licensing forms by mail, send request to: Department of Insurance, 320 Capitol Mall, Sacramento, CA 95814-4309, or you may phone Sacramento toll free at (800) 967-9331.

Mail application with attachments and fees to Department of Insurance, 320 Capitol Mall, Sacramento, CA 95814-4309.

Page 6 of 6

LIC 441-9 (Rev. 01/2021)

How to Edit Application Insurance License Online for Free

Our PDF editor helps make completing files stress-free. It is really straightforward to enhance the [FORMNAME] form. Consider the next steps so that you can do it:

Step 1: Step one would be to click on the orange "Get Form Now" button.

Step 2: At the moment, you are able to change your application insurance license print. Our multifunctional toolbar enables you to add, remove, adjust, highlight, as well as do similar commands to the words and phrases and areas inside the form.

These areas are included in the PDF template you will be filling in.

naic application forms empty fields to fill in

Remember to fill out the Business Address PO Box not, City, Business Phone Number, Business Fax Number I, Email Address required I, Are you affiliated with a, Zip Code I Business Web Site, Mailing Address PO Box is, City, State I, Zip Code I, Special Accommodation Request for, Examination Information If, Form LIC must be completed and, and Disclosure of your US social area with the demanded information.

Finishing naic application forms step 2

In the section referring to Name, City, Name, City, Name, City, Name, City, From Month Year I, To Month Year I, Position Held, State, State, State, and State, you will need to write down some required data.

part 3 to completing naic application forms

You have to spell out the rights and obligations of every party in part Last, Last, First, Middle, Suffix, Dates Used Reason Used, First, Middle, Suffix, Dates Used Reason Used, Fictitious Names, Do you intend to use a fictitious, If yes list the name This name, Yes, and LifeOnly AgentPart Time Fraternal.

Filling out naic application forms stage 4

Finish by analyzing the following sections and submitting the required data: If you fail to fully disclose any, Have you ever been convicted of a, No Yes, For the purpose of this, If you answer Yes to this, a a written statement with, and, b certified copies of the charging, resolution of the charges, Federal law USC prohibits, a Have you ever been convicted of, For the purpose of this, and No Yes.

part 5 to entering details in naic application forms

Step 3: Press the button "Done". The PDF form may be transferred. You can easily obtain it to your laptop or email it.

Step 4: Make duplicates of your file - it can help you prevent potential future worries. And don't be concerned - we do not publish or watch the information you have.

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