De Ins Form Illinois PDF 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?Yes
Fillable fields60
Avg. time to fill out12 min 15 sec
Other namesil486 1280, Additionally, de ins form illinois, IL486-1280

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)

How to Edit De Ins Form Illinois Online for Free

You can complete the ILCS form with this PDF editor. These actions will assist you to immediately create your document.

Step 1: Select the "Get Form Now" button to get started on.

Step 2: Right now, you can change the ILCS. The multifunctional toolbar will let you include, get rid of, change, highlight, and also perform several other commands to the text and areas inside the form.

Fill in the next areas to prepare the form:

entering details in seg part 1

Complete the INSURANCE COMPANY/INSURANCE, STREET, STATE, Area Code ( ) , / / Month Day Year, / / Month Day Year, and The comprehensive commercial areas with any information that can be asked by the program.

seg INSURANCE COMPANY/INSURANCE, STREET, STATE, Area Code (    )        ,   /   /     Month Day Year,   /   /     Month Day Year, and The comprehensive commercial blanks to fill

It is necessary to put down certain information inside the field The comprehensive commercial, IL486-1280 1/13 (DE), Signature of Agent, and Date.

Filling in seg step 3

Step 3: As soon as you are done, click the "Done" button to export your PDF document.

Step 4: To prevent yourself from any type of issues in the long run, you will need to prepare minimally several duplicates of your document.

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