Insurer Details

In order to complete a De Ins Form Illinois, you will need to provide your full name, date of birth, Social Security number, and current address. The form is available on the Secretary of State website and can be filled out and submitted electronically or through the mail. As with any legal document, it's important to make sure all information is accurate and up-to-date before submitting. Doing so can help ensure a smooth application process.

Before you decide to fill in de ins form illinois, you should know more concerning the type of form you'll use.

QuestionAnswer
Form NameDe Ins Form Illinois
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesinsurer, seg, Additionally, referenced

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

5. NEW APPLICANTS ONLY

 

 

 

 

 

 

 

 

 

 

Address of insured's location covered by insurance policy.)

 

 

 

 

 

 

 

 

 

 

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

 

 

 

 

 

 

 

 

 

 

 

 

 

119 -

 

 

 

 

 

 

 

 

 

 

 

time.)

 

 

 

 

 

 

 

 

 

 

 

 

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

 

 

124 -

 

 

 

 

 

 

 

 

 

 

 

 

191 -

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Under penalties of perjury, I declare that I have examined the policy this completed form, and to the best of my knowledge, 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 policy required by must include coverage for errors and omissions, 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 employment. 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. Insurance liability policies must be obtained from an insurer authorized by the Division of Insurance to do surety business in Illinois. Under penalties of perjury, I declare that I am an authorized agent of the above insurance company and licensed in Illinois as a producer; I have examined the policy referenced above and this application, and to the best of my knowledge, the policy meets the requirements 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 02/08 (DE)