De Ins Form Illinois PDF Details

Navigating the prerequisites for licensure in various professions within Illinois necessitates a careful adherence to the guidelines set forth by the state, particularly when it comes to fulfilling insurance requirements. The DE Ins Illinois form plays a crucial role in this process, acting as a supporting document that is indispensable for those seeking licensure or renewal under the Illinois Compiled Statutes (225 ILCS DE-INS 446/1 et. seq.). The completion of this form, while voluntary, is essentially mandatory as failure to comply could prevent the processing of pertinent documents. Designed to be completed by the applicant in conjunction with their authorized insurance agent, the form requires detailed information including the applicant’s name, personal identification details, and a description of the insurance policy, among other specifics. It serves to certify that the individual license holder carries comprehensive, commercial general liability insurance—a requirement that not only ensures compliance but also fosters a sense of trust and accountability in professional practices. Moreover, for those licensed under the Private Detective, Private Alarm, Private Security, Fingerprint Vendor, and Locksmith Act, this form confirms the necessary liability coverage is in place, extending to specific conditions such as bodily injury, property damage, and even incidents involving the use of firearms in the line of duty. The form also stipulates that, should the policy be terminated before its expiration, the insurer must notify the Department of Financial and Professional Regulation, underscoring the importance of maintaining coverage and the state’s commitment to professional integrity and public safety.

QuestionAnswer
Form NameDe Ins Form Illinois
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namessurety, insurer, licensure, il486 de ins

Form Preview Example

IMPORTANT NOTICE: Completion of this form is

 

SUPPORTING DOCUMENT

necessary for consideration for licensure under 225 ILCS

 

DE-INS

446/1 et. seg. (Illinois Compiled Statutes). Disclosure of

CERTIFICATE OF INSURANCE

this information is VOLUNTARY. However, failure to

comply may result in this form not being processed.

 

 

 

 

 

APPLICANT: Complete the applicant section of this form, then have your authorized insurance agent complete the remainder of the form. The completed form must be submitted WITH your application for licensure or renewal form. Insurance must be in the name of the individual license holder. The comprehensive, commercial general liability insurance must be in the name of the individual licensee.

1.

NAME OF INSURED (must be exactly as it appears on application,

2.

DATE OF BIRTH

 

3. SOCIAL SECURITY NUMBER

 

renewal form of individual license.)

__ __ / __ __ / __ __ __ __

 

__ __ __ - __ __ - __ __ __ __

 

 

 

 

 

Month Day

 

 

Year

 

 

 

 

 

 

 

 

 

 

4.

ADDRESS STREET, CITY, STATE, ZIP CODE (specific address

5.

NEW APPLICANTS ONLY

 

 

 

 

 

 

 

 

 

 

as noted on license)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

REFER TO REFERENCE SHEET. Record profession name and three digit

 

 

 

 

profession code for which you are making Illinois application.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Profession Name

 

 

Profession Code

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

6.

MAIDEN OR GIVEN SURNAME

7. RENEWAL APPLICANTS AND PERSONS VERIFYING CURRENT

 

 

 

INSURANCE

 

ONLY -- Record each individual license number you hold

 

 

 

under the Private Detective, Private Alarm, Private Security, Fingerprint

 

 

 

Vendor, and Locksmith Act.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

115 -

 

 

 

 

 

 

 

 

 

 

8.

TELEPHONE NUMBER (where you can be reached during the day-

 

 

 

 

 

 

 

 

 

 

 

 

 

 

time)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

119 -

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Area Code ( ___ ___ ___ ) ___ ___ ___ _ ___ ___ ___ ___

 

 

 

 

124 -

 

 

 

 

 

 

 

 

 

 

 

 

 

191 -

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Under penalties of perjury, I declare that I have examined the policy and this completed form and to the best of my knowl- edge, the statement is true, correct, and complete.

Signature of Applicant/LicenseeDate

INSURANCE COMPANY/INSURANCE PRODUCER: Complete the following information and return the form to the applicant licensed under the Private Detective, Private Alarm, Private Security, Fingerprint Vendor, and Locksmith Act.

A. NAME OF INSURANCE COMPANY

B. NAME OF AUTHORIZED AGENCY/PRODUCER

 

 

 

 

C. INSURANCE COMPANY HOME ADDRESS:

D. NAME AND ADDRESS OF AGENT'S BUSINESS: STREET, CITY,

STREET, CITY, STATE, ZIP CODE

STATE, ZIP CODE

 

 

 

 

 

 

 

E. INSURED'S POLICY NUMBER

F. TITLE OR TYPE OF POLICY

 

 

 

 

 

G. AGENT'S BUSINESS TELEPHONE NUMBER

H. EFFECTIVE DATE OF POLICY

I. EXPIRATION DATE OF POLICY

Area Code ( ___ ___ ___ ) ___ ___ ___ _ ___ ___ ___ ___

__ __ / __ __ / __ __ __ __

__ __ / __ __ / __ __ __ __

Month Day

Year

Month Day

Year

 

The comprehensive commercial general liability insurance policy, with proof of a minimum of $1,000,000 of liability insurance, must include coverage for bodily injury liability, property damage and personal injury. If the licensee carries a firearm in the course of duty, coverage must extend to claims for injury or damage resulting from the use of firearms while acting in the course of employ- ment. Additionally, if the licensee serves as the licensee in charge of an agency, and the licensee in charge of that agency permits anyone associated with it to carry a firearm, then coverage must extend to claims for injury or damage resulting from the employee's use of firearms while acting in the course of employment. Under penalties of perjury, I declare that I am an autho- rized agent of the above insurance company; I have examined the policy referenced above and this application, and to the best of my knowledge, the policy meets the requirements and provides liability coverage for the licensee's operations in the State of Illinois and statements made here are true, correct and complete. If this policy is terminated prior to expiration, the insurer agrees to provide written notice to the Department of Financial and Professional Regulation thirty (30) days prior to cancellation.

Signature of Agent

Date

IL486-1280 1/13 (DE)

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Complete the INSURANCE COMPANYINSURANCE, A NAME OF INSURANCE COMPANY, B NAME OF AUTHORIZED AGENCYPRODUCER, C INSURANCE COMPANY HOME ADDRESS, STREET CITY STATE ZIP CODE, D NAME AND ADDRESS OF AGENTS, STATE ZIP CODE, E INSUREDS POLICY NUMBER, F TITLE OR TYPE OF POLICY, G AGENTS BUSINESS TELEPHONE NUMBER, H EFFECTIVE DATE OF POLICY, I EXPIRATION DATE OF POLICY, Area Code, Month Day Year, and Month Day Year areas with any information that can be asked by the program.

IL486-1280 INSURANCE COMPANYINSURANCE, A NAME OF INSURANCE COMPANY, B NAME OF AUTHORIZED AGENCYPRODUCER, C INSURANCE COMPANY HOME ADDRESS, STREET CITY STATE ZIP CODE, D NAME AND ADDRESS OF AGENTS, STATE ZIP CODE, E INSUREDS POLICY NUMBER, F TITLE OR TYPE OF POLICY, G AGENTS BUSINESS TELEPHONE NUMBER, H EFFECTIVE DATE OF POLICY, I EXPIRATION DATE OF POLICY, Area Code, Month Day Year, and Month Day Year blanks to fill

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