Arkansas Form Aid Li Tagy PDF Details

The Arkansas Aid Li Tagy form, a critical document issued by the Arkansas Insurance Department's License Division, serves as a comprehensive means for business entities within the insurance sector to facilitate their licensure and operational declarations. Located at 1200 West 3rd Street, Little Rock, AR 72201, this form is designed to encapsulate vital information including the business entity’s name, incorporation details, Federal Employer Identification Number (FEIN), and any assumed names under which the entity might operate. It further delves into the specifics of the entity’s affiliations, particularly with financial institutions, and requires detailed identification of licensed title agents alongside owners, partners, officers, and directors with significant interest or voting rights. Moreover, it necessitates disclosures concerning past criminal convictions, administrative proceedings concerning professional licenses, financial insolvencies, delinquent tax obligations, involvement in legal matters related to fraud or misconduct, and any prior terminations of insurance agency contracts due to alleged misconduct. This rigorous documentation process, underscored by a certification and attestation section, ensures that entities are vetted thoroughly, promoting regulatory compliance and accountability within Arkansas's insurance industry. Such intricate requirements highlight the form's role not just as a procedural necessity but as a tool for maintaining the integrity and reliability of the insurance sector in Arkansas.

QuestionAnswer
Form NameArkansas Form Aid Li Tagy
Form Length3 pages
Fillable?No
Fillable fields0
Avg. time to fill out45 sec
Other names

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FORM AID-LI-TAGY (9/07)

ARKANSAS INSURANCE DEPARTMENT

LICENSE DIVISION

1200 WEST 3RD STREET

LITTLE ROCK, AR 72201

PHONE: 501-371-2750

FAX: 501-683-2604

TITLE AGENCY

(Please Print or Type)

1

Business Entity Name

 

2 Incorporation/Formation

3 FEIN

 

 

 

Date

-

 

 

 

 

 

4

If assigned, National Producer Number (NP#)

5 If applicable, NASD Firm Central Registration Depository (CRD) Number

 

 

 

 

 

6List any other assumed, fictitious, alias or trade names under which you are doing business or intend to do business.

7State of Domicile

8Country of Domicile

9 Is the business entity affiliated with a financial institution/bank?

Yes

No

10Business Address

11City

12State

13Zip Code

14Foreign Country

15

Phone Number

16 Fax Number

17 Business Web Site Address

18 Business E-Mail Address

 

 

(

)

-

(

)

-

 

 

 

 

19

Mailing Address

 

20

P.O. Box

21 City

22 State 23 Zip Code

24Foreign Country

Designated/Responsible Licensed Title Agent

25Identify all Licensed Title Agents:

Name

 

SSN

-

-

Name

 

SSN

-

-

Name

 

SSN

-

-

Name

 

SSN

-

-

Owners, Partners, Officers and Directors

26Identify all owners with 10% interest or voting interest, partners, officers and directors of the business entity:

Name

 

Title

SSN/FEIN

-

-

Owner: Yes / No

 

 

 

 

 

 

 

 

 

Name

 

Title

SSN/FEIN

-

-

Owner: Yes / No

 

 

 

 

 

 

 

 

Name

 

Title

SSN/FEIN

-

-

Owner: Yes / No

 

 

 

 

 

 

 

 

Name

 

Title

SSN/FEIN

-

-

Owner: Yes / No

 

 

 

 

 

 

 

 

Name

 

Title

SSN/FEIN

-

-

Owner: Yes / No

Name

 

 

 

 

 

 

 

 

Title

SSN/FEIN

-

-

Owner: Yes / No

 

 

 

 

 

 

 

 

Name

 

Title

SSN/FEIN

-

-

Owner: Yes / No

 

 

 

 

 

 

 

 

Name

 

Title

SSN/FEIN

-

-

Owner: Yes / No

 

 

 

 

 

 

 

 

 

(State Use)

Form AID-LI-TAGY(9/07)

Page 2

Jurisdiction and Type of License/Registration Requested –

27Next 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

LLC – Limited Liability Company

LLP – Limited Liability Partnership

Background Information

28Please read the following very carefully and answer every question. All copies of documents must be certified. All written statements submitted by the Applicant must include an original signature.

1. Has the business entity or any owner, partner, officer or director ever been convicted of, or is the business entity or any owner, partner,

Yes ___

No___

 

officer or director currently charged with, committing a crime, whether or not adjudication was withheld?

 

 

 

“Crime”

includes a misdemeanor , felony or a military offense. You may exclude misdemeanor traffic citations 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

 

 

 

contendre, 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

certified copy of the charging document, and

 

 

 

c)

a

certified 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 ever been involved in an administrative proceeding regarding any

Yes ___

No___

 

professional or occupational license?

 

 

 

 

 

 

 

 

 

 

“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 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. “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 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 certified copy of the Notice of Hearing or other document that states the charges and allegations, and

 

 

 

c) a certified 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 the business entity or any owner, partner, officer or director for overdue

Yes ___

No___

 

monies by an insurer, insured or producer, or have you ever been subject to a bankruptcy proceeding?

 

 

 

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 ever been notified by any jurisdiction to which you are applying of any

Yes ___

No___

 

delinquent tax obligation that is not the subject of a repayment agreement?

 

 

 

If you answer yes, identify the jurisdiction(s): _______________________________________

 

 

 

5. Is the business entity or any owner, partner, officer or director a party to, or ever been found liable in any lawsuit or arbitration proceeding

Yes ___

No___

 

 

 

 

involving allegations of fraud, misappropriation or conversion of funds, misrepresentation or breach of fiduciary duty?

 

 

 

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

 

 

 

a)

a written statement summarizing the details of each incident,

 

 

 

b)

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

 

 

 

c)

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

 

 

6. Has the business entity or any owner, partner, officer or director ever had an insurance agency contract or any other business relationship

Yes ___

No___

 

with an insurance company 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)certified copies of all relevant documents.

Form AID-LI-TAGY(9/07)

Page 3

Applicants Certification and Attestation

29The undersigned owner, partner, officer or director of the business entity 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 to civil or criminal penalties.

2.Where required by law, the business entity 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 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 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 give any information they may have concerning me 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 comply with the insurance laws and regulations of the jurisdictions to which I am applying for licensure/registration.

7.If required, I have received a Certificate of Good Standing from the jurisdiction's Secretary of State in which I am applying.

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-resident state.

Attachments

Must be signed by an officer, director, principal or partner of the business entity:

Month DayYear

____________________________________________

Signature

_________________________________________________

Typed or Printed Name

_________________________________________________

Title

_________________________________________________

Social Security Number

_________________________________________________

Address

_________________________________________________

City

State

Zip

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