Insurance License Application Details

In order to be eligible for a license as a life and health insurance agent, you must first complete the required licensing courses. One of these requirements is an application insurance license which can be obtained through the state's Department of Insurance. This article will explain how to obtain your application insurance license in California. To receive this type of license, applicants must have at least one year experience as a licensed agent or broker with general lines property and casualty licenses from another state or country. In addition, they must also provide proof that they are qualified by completing two exams: General Lines Property and Casualty Exam (GLPC) and Life Health Basic exam (LHB).

We've gathered some statistical information about the application insurance license. This page provides details about the form's length, finalization duration, and the areas you may be required to fill.

QuestionAnswer
Form NameApplication Insurance License
Form Length5 pages
Fillable?No
Fillable fields0
Avg. time to fill out1 min 15 sec
Other namesuniform application producer registration, how to application individual, application producer, naic uniform insurance

Form Preview Example

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

1Soc. Security Number

--

2If assigned, National Producer Number (NPN)

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

4 Last Name

JR./SR. etc

5First Name

6Middle Name

7Date of Birth

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

8 Residence/Home Address (Physical Street)

9City

10State

11Zip Code

12Foreign Country

13 Home Phone Number

14 Gender (Circle One)

(

)

-

Male Female

Individual

Applicant Email Address:

 

15Are 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.)

16Business Entity Name

17

Business Address (Physical Street)

 

 

18 P.O. Box

19

City

20

State

21 Zip Code

22

Foreign Country

23

Business Phone Number (include

24 Business Fax Number

25

Business E-Mail Address

 

26 Business Web Site Address

 

extension)

 

(

)

-

 

 

 

 

 

 

 

 

(

)

-

 

 

 

 

 

 

 

 

 

 

27

Applicant’s Mailing Address

 

 

28 P.O. Box

29

City

30

State

31 Zip Code

32

Foreign Country

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)

FEIN ________________________

NPN ___________________

Name of Agency ___________________________________________________________

FEIN ________________________

NPN ___________________

Name of Agency ___________________________________________________________

FEIN ________________________

NPN ___________________

Name of Agency ___________________________________________________________

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.

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)

© 2011 National Association of Insurance Commissioners

Page 1 of 5

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.

License Types:

 

 

 

 

A – Agent

 

 

 

 

B – Broker

 

 

P - Producer

SLP – Surplus Lines Producer

 

 

 

 

 

 

 

 

 

 

 

V – Variable

 

 

 

 

 

 

 

 

H – Accident &

 

 

 

 

 

 

 

 

 

 

 

 

 

Lines of Authority:

 

 

 

L – Life

 

 

 

 

Health or

P – Property

 

 

C – Casualty

 

PL – Personal Lines

 

 

Life/Variable Annuity

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Sickness

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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WI

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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© 2011 National Association of Insurance Commissioners

Page 2 of 5

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.

1. Have you ever been convicted of a crime, had a judgment withheld or deferred, or are you currently charged with committing a crime?

Yes ___ No___

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

insurance in your home state as required by 18 USC 1033?

N/A_____ Yes_____ No _____

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

N/A _____ Yes ____ No _____

2. Have you 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 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

 

a bankruptcy proceeding? Do not include personal bankruptcies, unless they involve funds held on behalf of others

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?

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 or arbitration, or mediation proceedings, and

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

© 2011 National Association of Insurance Commissioners

Page 3 of 5

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

misconduct?

Yes ___ No___

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

a)a written statement summarizing the details of each incident and explaining why you feel this incident should not prevent you from receiving an insurance license, and

b)copies of all relevant documents.

 

 

Yes ___

No___

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

 

 

If you answer yes,

_________Months

a)

by how many months are you in arrearage?

Yes ___

No___

b)

are you currently subject to and in compliance with any repayment agreement?

Yes ___

No___

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.)

8). In response to a “yes” answer to one or more of the Background Questions for this application, are you submitting 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 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___

© 2011 National Association of Insurance Commissioners

Page 4 of 5

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).

© 2011 National Association of Insurance Commissioners

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