Application Insurance License – Fill Out and Use

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.

Uniform Application for

Individual Producer License/Registration

(Please Print or Type)

Check appropriate box for license requested.

Resident License

Non-Resident License

• Identify Home State: ____________________

Demographic Information

3If applicable, FINRA Individual Central Registration Depository (CRD) Number

16Business Entity Name

33a. 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

34List your Insurance Agency Affiliations: (Complete only if the applicant is to be licensed as an active member of the business entity)

Employment History

35Account 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.

Name

Name

Name

Name

(State Use)

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.

Uniform Application for

Individual Insurance Producer License/Registration

Jurisdiction and Type of License Requested

36Next to each jurisdiction, check the license type(s) and line(s) of authority for which you are applying.

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

Uniform Application for

Individual Insurance Producer License/Registration

Background Information

37The Applicant must read the following very carefully and answer every question. All written statements submitted by the Applicant must include an original signature.

Note: “Crime” includes a misdemeanor, a felony or a military offense.

You may exclude misdemeanor traffic citations and misdemeanor convictions or pending misdemeanor charges involving driving under the influence (DUI) or driving while intoxicated (DWI), driving without a license, reckless driving, or driving with a suspended or revoked license and juvenile offenses.

“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, 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.

If you have a felony conviction involving dishonesty or breach of trust, have you applied for written consent to engage in the business of

“Involved” means having a license censured, suspended, revoked, canceled, terminated; or, being assessed a fine, a cease and desist order, a prohibition order, a compliance order, placed on probation, sanctioned or surrendering a license to resolve an administrative action. “Involved” also means being named as a party to an administrative or arbitration proceeding, which is related to a professional or occupational license, or registration. “Involved” also means having a license, or registration application denied or the act of withdrawing an application to avoid a denial. INCLUDE any business so named because of your actions,in your capacity as an owner, partner, officer or director, or member or manager of a Limited Liability Company. You may EXCLUDE terminations due solely to noncompliance with continuing education requirements or failure to pay a renewal fee.

If you answer yes, you must attach to this application:

a)a written statement identifying the type of license and explaining the circumstances of each incident,

b)a copy of the Notice of Hearing or other document that states the charges and allegations, and

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

3.Has any demand been made or judgment rendered against you or any business in which you are or were an owner, partner, officer or director, or member or manager of a limited liability company, for overdue monies by an insurer, insured or producer, or have you ever been subject to

If you answer yes, you must attach to this application:

a)a written statement summarizing the details of each incident,

b)a copy of the Petition, Complaint or other document that commenced the lawsuit or arbitration, or mediation proceedings, and

c)a copy of the official documents, which demonstrates the resolution of the charges or any final judgment.

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.

Uniform Application for

Individual Insurance Producer License/Registration

6.Have you or any business in which you are or were an owner, partner, officer or director, or member or manager of a limited liability company, ever had an insurance agency contract or any other business relationship with an insurance company terminated for any alleged

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.

c)are you the subject of a child support related subpoena/warrant?

(If you answered yes, provide documentation showing proof of current payments or an approved repayment plan from the appropriate state child support agency.)

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.

Uniform Application for

Individual Insurance Producer License/Registration

Applicant’s Certification and Attestation

38The 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, to any federal, state or municipal agency, or any other organization and I release the jurisdictions and any person acting on their behalf from any and all liability of whatever nature by reason of furnishing such information.

6.I acknowledge that I understand and 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.

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).

__________________________________________________

Month/Day/Year

_________________________________________________________________

Original Applicant Signature

_________________________________________________________

Full Legal Name (Printed or Typed)

Attachments

39The 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).