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| Question | Answer |
|---|---|
| Form Name | Form Aid Li Mga40 |
| Form Length | 2 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 30 sec |
| Other names | mga_application mga license in arkansas form |
FORM
ARKANSAS INSURANCE DEPARTMENT
LICENSE DIVISION
1200 WEST 3RD STREET
LITTLE ROCK, AR 72201
PHONE:
FAX:
MANAGING GENERAL AGENT INSURANCE LICENSE APPLICATION
(CORPORATION, LLC, LLP, AND PARTNERSHIP)
Check appropriate line for license requested:
Resident License
Identify Home State: ______________________ Identify Home State License # ___________________
1.Business Entity Name____________________________________________________________________
2.FEIN _____________________________________
3.State of Domicile ___________________________
4.Business Address: _______________________________________________________________________
Street |
City |
State |
Zip |
5. Phone number________________________________ |
Fax # ____________________________ |
||
6.Mailing Address ________________________________________________________________________
P.O. Box or Street |
City |
State |
Zip |
7.Contact Person for MGA:
Name_____________________________________________ Phone #_____________________________
8.Owners, Partners, Officers and Directors: Can attach list to application if additional space is needed:
Name ______________________________________ Title______________________________________
Name ______________________________________ Title______________________________________
Name ______________________________________ Title______________________________________
Name ______________________________________ Title______________________________________
Name ______________________________________ Title______________________________________
9.Name of Insurance Company/Companies, which the MGA will represent: Attach a completed
Company NAIC # _________________ Company Name ________________________________________
Company NAIC # _________________ Company Name ________________________________________
10.List Name of Errors and Omissions Carrier, Policy Number and Effective Date:
Carrier Name: ________________________________ Policy # _________________ Date _____________
11.List name of Company issuing surety bond on the MGA, Policy Number and Effective Date:
Company Name: ______________________________ Bond # __________________ Date ____________
FORM
PLEASE READ THE FOLLOWING VERY CAREFULLY AND YOU MUST ANSWER EVERY QUESTION. IF ANY OF THE QUESTIONS IS ANSWERED
12.Has the business entity or any owner, partner, officer or director ever been convicted of, or is the business entity or any owner, partner, officer or director currently charged with, committing a crime, whether or not
adjudication was withheld? |
Yes |
No |
13. Has the business entity or any owner, partner, officer or director ever been involved in an administrative
proceeding regarding any professional or occupational license? |
Yes |
No |
14.Has any demand been made or judgment rendered against the business entity or any owner, partner, officer or director for overdue monies by an insurer, insured, or producer, or has any of these entities been subject
to a bankruptcy proceeding? |
Yes |
No |
15.H the business entity or any owner, partner, officer or director ever been notified by any jurisdiction to which you are applying of any delinquent tax obligation that is not the subject of a repayment agreement?
Yes |
No |
16. Is the business entity or any owner, partner, officer or director a party to, or ever been found liable in any lawsuit or arbitration proceeding involving allegations of fraud, misappropriation or conversion of funds,
misrepresentation or breach of fiduciary duty? |
Yes |
No |
17.Has the business entity or any owner, partner, officer, or director ever had an insurance agency contract or any other business relationship with an insurance company terminated for any alleged misconduct?
Yes |
No |
APPLICANTS CERTIFICATION AND ATTESTATION
The undersigned owner, partner, officer or director of the business entity hereby certifies, under penalty, that:
All of the information submitted in this application and attachments is true and complete and I am aware that submitting false information or omitting pertinent or material information in connection with this application is grounds for license or registration revocation and may subject me and the business entity to civil or criminal penalties.
The business entity grants permission to the Commissioner to verify any information supplied with any federal, state, or local government agency, current or former employer or insurance company.
Every owner, partner, officer or director of the business entity either (a) does not have a current child support obligation, or (b) has a child support obligation and is currently in compliance with that obligation.
I authorized the jurisdictions to give any information they may have concerning me to any federal, state or municipal agency, or any other organization and I release the jurisdictions and any person acting on their behalf from any and all liability of whatever nature by reason of furnishing such information.
I acknowledge that I understand and comply with the insurance laws and regulations of the jurisdictions to which I am applying for licensure.
For
Must be signed by an Officer, Director, Principal or Partner of the business entity:
Date ______________________________________
___________________________________
Signature
__________________________________________
Typed or Printed Name
__________________________________________
Title
Note: The original Surety Bond and a copy of the Errors and Omissions Policy must be attached to this application.
Note: Must attach proof of filing with the Arkansas Secretary of State showing the business entity has filed as a foreign Corporation or Limited Liability Company with the State of Arkansas.