Form 1033 – Fill Out and Use This PDF

SHORT FORM APPLICATION

FOR WRITTEN CONSENT

TO ENGAGE IN

THE BUSINESS OF INSURANCE

PURSUANT TO

18 U.S.C. § 1033 AND 1034

SUBMIT TWO RECENT

IDENTICAL PHOTOS

Notice to Applicant: 18 U.S.C. § 1033 prohibits certain activities by or affecting persons engaged, or proposing to become engaged, in the business of insurance:

(e)(1)(A)	Any individual who has been convicted of any criminal felony involving dishonesty
	or a breach of trust, or who has been convicted of an offense under this section, and
	who willfully engages in the business of insurance whose activities affect interstate
	commerce or participates in such business, shall be fined as provided in this title or
	imprisoned not more than 5 years, or both.

(B)Any individual who is engaged in the business of insurance whose activities affect interstate commerce and who willfully permits the participation described in subparagraph (A) shall be fined as provided in this title or imprisoned not more than 5 years, or both.

(e)(2)	A person described in paragraph (1)(A) may engage in the business of insurance or
	participate in such business if such person has the written consent of any regulatory
	official authorized to regulate the insurer, which consent specifically refers to this
	section.

This Application will be reviewed by the chief insurance regulatory official in this state to determine whether the Applicant should be given written consent to engage in the business of insurance or participate in the business pursuant to 18 U.S.C. § 1033(e)(2).

You must answer every question on the Application. If a question does not apply, indicate N/A in the space provided for the answer. Your answers are not limited to the space provided on the Application. Attach additional pages as needed. The Department of Insurance will not process incomplete Applications. Additional information may be requested.

© 1998 National Association of Insurance Commissioners

PLEASE TYPE

SECTION I - APPLICANT INFORMATION

1.Full Name of Applicant:

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Last Name	First Name	Middle
Have you ever been known by or used another name, including maiden name? o yes			o no

If yes, identify:_____________________________________________________________________________________

Home

Address:_________________________________________________________________________________________

Street Address	City	State	Zip
Mailing Address:___________________________________________________________________________________
P.O. Box or Street Address	City	State	Zip

Home Telephone Number:_____________________________

Work Telephone Number:_____________________________

Social Security No._________________________

Have you ever used or been issued another social security number?_________ If so, provide an explanation and

previous/other social security number(s) ______________________________________________________________

Place and Date of Birth:_____________________________________________________________________________

(Answer all questions fully and completely. Failure to answer the questions fully will result in delays in the application process. You are not limited to the space below. Attach additional pages if needed).

SECTION II - CRIMINAL HISTORY

1.List any felony(s) for which you have been arrested, charged, indicted, or convicted. Include details of any negotiated plea agreements and pleas of nolo contendre to an Information or indictment. Attach a full description of your acts involved in the aforementioned matters. Include dates of charge, location, and nature of offense. Attach additional pages if needed.

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2.Provide details of the conviction for which you are seeking written consent and the final disposition of these matter(s) , including sentence; dates of incarceration; dates of probation/parole (if you are currently under probation/parole, include the name and phone number of person supervising your parole or probation; restitution paid; fines/costs ordered: fines/costs paid; and pardons granted. Include information as to whether or not your civil and political rights have been restored. Attach additional pages if needed.

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SECTION III - PRESENT/PROPOSED INSURANCE EMPLOYMENT

1.Please specify the name and address of your current or proposed employer to which the requested exemption will apply.

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2.Please describe in detail the office, position, and title. to which the requested exemption will apply and a complete description of the activities, duties and responsibilities. Please attach or describe any proposed or current written or oral agreements, contracts, or understandings with any entity engaged in the business of insurance as defined by 18 U.S.C. § 1033. (If consent is given, it will be applicable to the

activities described herein.) Please include your date of employment or proposed date of employment.

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SECTION IV - ATTACHMENTS

Attach the following documents to this Application for written consent. Applications without attachments, or applications with incomplete attachments, will be returned to the applicant.

1.Certified copy of the applicant’s criminal history.

2.Certified copy of the indictment, criminal complaint, or docket sheet or other initiating documents for the charge(s) which is the subject of this Application.

3.A certified copy of the order of judgment and sentence of the court for the conviction that is the subject of this Application, including certification of completion and performance of all conditions imposed by the court.

4.An affidavit from the individual that seeks to employ you stating in detail the duties and responsibilities that you are performing or are to perform for them and for which you seek written consent and that it is that individual’s opinion that the performance of these responsibilities does not constitute a threat to the public.

I, ___________________________________ (name of applicant), swear under penalty of law that my

statements in the attached Application, and the documents appended thereto, are true and correct and complete. I understand that my statements in the Application and the attachments to my Application will be relied upon by the Insurance Commissioner of the State of

____________________ in the execution of his or her duties under the Insurance Code, and 18

U.S.C. § 1033, in making a decision on this Application. I understand that if I have made any false statement in this Application, or if there are any false statements included in the attachments to this Application, I may be criminally prosecuted under any state criminal or administrative remedies available and that any insurance license(s) that I currently hold, or for which I have applied, will be subject to suspension or revocation. I further understand that these false statement(s) would also constitute a violation of 18 U.S.C. § 1033. For purposes of this Application, I do not contest the validity of any felony conviction upon which this request would be granted. By signing this

Application, I acknowledge that the Insurance Department, for the State of______________

________ may conduct an independent investigation to confirm the information in this

Application and I expressly consent and authorize any person, business or agency to release any information the Insurance Department may request as part of the investigation, including but not limited to, records of my former employment, state and federal tax

returns, business records, and banking records.

	___________________________________________________________
	Signature of Applicant	Date
STATE OF ______________ )
	)
COUNTY OF __________	)
Subscribed, sworn to, and acknowledged before me by ___________________________________ to be his/her free act
and deed this _____ day of ____________________, 19_____.
	___________________________________________________________
	Notary Public, State at Large	My Commission Expires

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