Form LIC-441-9 at a glance
What it is: Form LIC-441-9 is the State of California Department of Insurance Individual Application For Insurance License.
Where and when to file: Mail application with attachments and fees to Department of Insurance, 300 Capitol Mall, 16th Floor, Sacramento, CA 95814-4313.
What to bring and attach to Form LIC-441-9
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.
If you apply for Surplus Line Broker (SL)* or Special Lines' Surplus Line Broker (SP)* (not Part Time Fraternal Agent (PF), Portable Electronics Agent (PE) or Car Rental Agent (RC)), Form LIC 050 must be completed and submitted with Surplus and/or the Special Lines' Surplus Broker Application.
A filled-in Form LIC-441-9 example: a new applicant seeks a permanent license
How to fill out Form LIC-441-9, box by box
Application Type
In Box 1, mark the Application Type, Permanent or Certificate of Convenience (not For Department Use Only).
License Type
In Box 2, mark the License Type: Accident & Health or Sickness (AH), Life Agent (LO), Variable Life and Variable Annuity (VC), Property Broker-Agent (PR), Casualty Broker-Agent (CA), Personal Lines Broker-Agent (PL). Limited Lines Auto Insurance Agent (AU), Credit Insurance Agent (CI), Part Time Fraternal Agent (PF), Portable Electronics Agent (PE), Car Rental Agent (RC), Surplus Line Broker (SL), Special Lines' Surplus Line Broker (SP). Self-Service Storage Agent (SS), Title Marketing (TM), Burial and Funeral Expenses (LOLP), Life & Disability Analyst (LA), Motor Club Agent (MC), Cargo Shipper's Agent (CS) or Vehicle Service Contract Provider (VS).
Name, Male Female, Birthdate, Social Security Number
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.
Mark Male or Female in Box 4, enter the Birthdate (MM/DD/YYYY) in Box 5 and the Social Security Number or Individual Tax Identification Number in Box 6.
Resident Address
Enter the Resident Address in Box 7, then the City, State and Zip Code. P.O. Box not acceptable. Do not enter the word "same" in any address area.
Home Phone Number, citizen and financial institution/bank
Enter the Home Phone Number in Box 11. In Box 12, mark Yes or No: Are you a citizen of the United States? In Box 13, mark Yes or No: Are you affiliated with a financial institution/bank?
Business Address, Phone, Fax, E-mail and Web Site
Enter the Business Address in Box 14, then the City, State and Zip Code. P.O. Box is not acceptable.
Enter the Business Phone Number in Box 18, the Business Fax Number in Box 19, the E-mail Address (required) in Box 20 and the Business Web Site Address in Box 21. Business and mailing addresses are public record and are available to the public.
Mailing Address
Enter the Mailing Address in Box 22, then the City, State and Zip Code. P.O. Box is acceptable.
Special Accommodation Request for Examination
26. Special Accommodation Request for Examination - If required, arrangements were made prior to taking and passing the license examination.
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.
Do you now hold an insurance license
29. Do you now hold, or have you ever held, an insurance license as a resident in this state or any other state? Yes No Type of License State or Province Date License Held Is License in Force?
AKA/Alias
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.
Fictitious Names
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)
Life-Only Agent/Part Time Fraternal
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)?
Enter the 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.
Prelicensing Certificates
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.
Background Information (1 to 3)
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.
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. You may exclude juvenile offenses tried in juvenile court.
1. Have you ever been convicted of a felony?
3. Have you ever been convicted of a misdemeanor?
Background Information continued (4 to 8)
34. Background Information continued. 4. Have you ever been convicted of a military offense?
5. Are you currently charged with committing a crime? "Crime" includes a felony, a misdemeanor or a military offense.
6. Have you ever been involved in an administrative proceeding (including matters with the Department of Insurance) regarding any professional or occupational license? "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. You may exclude terminations due solely to noncompliance with continuing education requirements or failure to pay a renewal fee.
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 or occupational license?
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 bankruptcies that involve funds held on behalf of others).
Background Information continued (9 to 11)
34. Background Information continued. 9. Have you ever been notified by any jurisdiction of any delinquent tax obligation that is not the subject of 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 fiduciary duty?
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 for any alleged misconduct?
Applicant's Certification
35. Applicant's Certification: By submitting this electronic application I certify that I have read the application and know the contents thereof and that each statement therein made is full, true and correct.
Sign as the applicant in Applicant's Signature, then enter the City and the Date.
More rules for Form LIC-441-9
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, 300 Capitol Mall, 16th Floor, Sacramento, CA 95814-4313
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.
Common questions about Form LIC-441-9
Where do I file it?
Mail application with attachments and fees to Department of Insurance, 300 Capitol Mall, 16th Floor, Sacramento, CA 95814-4313.
Are there fees?
All fees are filing fees and are not refundable, whether the is acted upon or an examination taken.
Sources
[1] Form LIC-441-9 (Rev 01/2023), Individual Application For Insurance License, California Department of Insurance (the Official source link on this page).
