Form 442 39A – Fill Out and Use This PDF

State of California	Department of Insurance
Live Scan Service Request (Applicant)
LIC 442-39A (Rev. 04/2013)

Attention:

Live Scan Service Providers, Resident and Nonresident License Applicants, and

1033 Consent Waiver (18 U.S.C. §1033) Applicants

The California Department of Justice (DOJ) and Federal Bureau of Investigation’s (FBI) processing fees are to be paid by the license applicant. Be prepared to pay the fees at the time your fingerprints are taken at the license scan service provider site.

The applicant is to make two copies of this form and distribute as follows:

1)First Copy (Original) to the Live Scan Provider;

2)Second Copy to the Applicant.

If the applicant completes a 1033 Consent Waiver (18 U.S.C. §1033), that applicant is to make a Third Copy of this form and send it to the California Department of Insurance.

Part 1		Applicant’s’ Personal Information
		Please type or print clearly the information below
Applicant Name (Last, First, and Middle)
Former Name/AKA’s (Last, First)
Date of Birth (MM/DD/YYYY)		Gender □ Male □ Female	Height			Weight
Eye Color		Hair Color	Place of Birth
Social Security Number		Driver’s License Number	Daytime Telephone Number
			(	)

Residence Address (Street/PO Box, City, State, Zip Code)

Department and Live Scan Vendor ONLY

Part 2		To be completed by Contributing Agency
Agency ORI Number			Agency Address			OCA Number:
		A0042	California Department of Insurance				1000
			320 Capitol Mall, Sacramento, CA 95814
Application Type: (e.g. type of search)			Job Title:			Mail Code:
						(five-digit code assigned by DOJ)
	License Certificate or Permit			Insurance
							04605
Level of Service: California Department of Justice and Federal Bureau of Investigation
Part 3		To be completed by Live Scan Transaction
Live Scan Transaction Completed by: (Name of				Date Completed	Transmitting Agency			Terminal ID
operator)
Amount Collected (For rolling fee)				Amount Collected:	ATI Number
				(For DOJ/FBI Processing)
Part 4		To be completed by Live Scan for Fingerprint Resubmission
Original ATI Number			Level of Service Requested for Resubmission
			□ California Department of Justice		□ Federal Bureau of Investigation

Original - Live Scan operator, Second Copy - Requesting Agency, Third copy – Applicant

LIC 442-39A (Rev. 04/2013) – Page 2

Resident Producer Licensing Applicant Instructions

Step 1: Completion of Live Scan Form: The following information must be entered in Part 1 of the form by the applicant: Your printed name and former names (if any); Date of birth, gender, height, weight, eye color, hair color, place of birth, social security number (SSN), driver’s license number, and residence address. The contributing agency will complete Part 2. The live scan vendor will complete Part 3 and, if necessary, Part 4 of this form.

Step 2: Producer Fingerprint Requirement: One set of classifiable electronic fingerprints is required for every California Department of Insurance (CDI) applicant unless the applicant is currently licensed or held a CDI license which expired during the last 12 months.

Step 3: Fingerprint Services: Live Scan Fingerprint Services available in California: The California Department of Justice (DOJ) maintains a listing of Live Scan fingerprinting services available to the public. The DOJ list is broken down by county. Fees vary from location to location. Applicants are encouraged to contact the Live Scan provider in advance to verify their current operating hours, fees, etc. This list is available at the following website: http://ag.ca.gov/fingerprints/publications/contact.php

For your convenience, CDI's contracted vendor, Accurate Biometrics will have staff available at the CDI’s examination sites to complete the fingerprint impression requirement.

Step 4: Fees: At CDI’s examination site, the total processing fee for the fingerprint impressions taken by CDI’s contracted vendor is $58.30 which includes the FBI processing fee of $17, DOJ processing fee of $32, and the CDI’s contractor’s rolling fee of $9.30. The $58.30 fee is to be paid at CDI’s examination site. The applicant may pay with all major credit cards — VISA, MasterCard, American Express and Discover Card. In addition, a money order, cashier’s check, company check or personal check in the amount of $58.30 made payable to "Accurate Biometrics” will also be accepted

At PSI’s test center, the total processing fee for the fingerprint impressions taken by L-1 Solutions is $68.95 which includes the FBI processing fee of $17, DOJ processing fee of $32, and the rolling fee charged by PSI of $19.95. The $68.95 fee is to be paid at the PSI test center. They accept money order, cashier’s check, company check (made payable to L-1 Solutions), VISA and MasterCard. Personal checks and cash will not be accepted.

In addition, applicants using a DOJ authorized vendor on DOJ’s LiveHScan Fingerprinting vendorsH list will need to pay a fingerprint fee that covers the FBI processing fee of $17, DOJ processing fee of $32, and an additional "rolling fee" charged by the DOJ authorized vendor. The additional "rolling fee" will vary depending on the vendor and is noted on DOJ's list of vendors. License applicants are encouraged to contact the Live Scan provider in advance to verify their current operating hours, location, fees, and their acceptable method of payment (i.e. credit card, cash, ATM).

Step 5: Submission of Fingerprint Form: Please take this form to the live scan provider for processing.

Non-Resident Producer Licensing Applicant Instructions

Step 1: Completion of Live Scan Form: The following information must be entered in Part 1 of the form by the applicant: Your printed name and former names (if any); Date of birth, gender, height, weight, eye color, hair color, place of birth, social security number (SSN), driver’s license number, and residence address. The contributing agency will complete Part 2 of this form. The electronic fingerprint service provider will complete Part 3 and, if necessary, Part 4 of this form.

Step 2: Mail Fingerprint Card, Live Scan Form & Fees Directly to Accurate Biometrics. Keep a copy of the Live Scan form your records. Mail original

copy of the completed Live Scan form along with your fingerprint card submission and Accurate Biometrics’ credit card payment form or check for $58.30 made payable to Accurate Biometrics to the following address: Accurate Biometrics, 455 Capitol Mall, Suite 233, Sacramento, CA 95814.

Step 3: Fees: The following fees must be paid by the non-resident applicant:

Processing Fee: The cost of the Accurate Biometrics’ live scan service is $58.30. The $58.30 processing fee covers the following services: Federal Bureau of Investigation fingerprint check is $17, State of California Department of Justice fingerprint check is $32 and Accurate Biometrics’ rolling fee is $9.30.

Service Fee: A separate fee will be charged for the service of taking the fingerprint impressions by a fingerprint technician or live scan fingerprints by the live scan provider. That fee may vary depending on the fingerprint vendor or live scan provider you choose.

1033 Consent Waiver (18 U.S.C. §1033) Applicants

Step 1: Completion of Live Scan Form: Follow same instructions as indicated above for resident license applicants.

Step 2: Fingerprint Services: Follow same instructions as indicated above for resident license applicants.

Step 3: Submission of Fingerprint: Follow same instructions as indicated above resident license applicants, however, a third copy of the Live Scan Form must be mailed to the California Department of Insurance, Licensing Background Bureau, 320 Capitol Mall, Sacramento, CA 95814-4309. The second copy is to be maintained by the applicant for your records.

Step 4: Fees: Follow the same instructions as indicated above for resident license applicants.