Form Aid Li Mga40 PDF Details

The Aid Li Mga40 form serves a critical role in the regulatory framework of the insurance industry in Arkansas, providing a standardized method for managing general agents (MGAs) to apply for their insurance licenses. These applications, governed by the Arkansas Insurance Department, are essential for corporations, limited liability companies (LLCs), limited liability partnerships (LLPs), and partnerships aiming to conduct insurance-related activities within the state. Whether seeking a resident or non-resident license, the form requires detailed information about the business entity, including its name, Federal Employer Identification Number (FEIN), state of domicile, business and mailing addresses, and the contact details of the person responsible for the MGA. Additionally, the form prompts applicants to disclose particulars about the owners, partners, officers, and directors, the insurance companies they intend to represent, and critical financial responsibility proofs such as errors and omissions policies and surety bonds. Furthermore, it delves into legal and financial backgrounds, querying about past convictions, administrative proceedings, financial judgments, delinquent taxes, involvement in lawsuits, and previous business relationship terminations for misconduct. Completing this form truthfully and comprehensively is mandatory, underscored by an attestation section that binds the applicant to the accuracy and completeness of the information provided, highlighting the seriousness with which the Arkansas Insurance Department treats these applications.

QuestionAnswer
Form NameForm Aid Li Mga40
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesmga_application mga license in arkansas form

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FORM AID-LI-MGA40 (2/05)

ARKANSAS INSURANCE DEPARTMENT

LICENSE DIVISION

1200 WEST 3RD STREET

LITTLE ROCK, AR 72201

PHONE: 501-371-2750

FAX: 501-683-2604

MANAGING GENERAL AGENT INSURANCE LICENSE APPLICATION

(CORPORATION, LLC, LLP, AND PARTNERSHIP)

Check appropriate line for license requested:

Resident License

Non-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 M-41 for each company listed. Company NAIC # _________________ Company Name ________________________________________

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 AID-LI-MGA40 (2/05) Page 2.

PLEASE READ THE FOLLOWING VERY CAREFULLY AND YOU MUST ANSWER EVERY QUESTION. IF ANY OF THE QUESTIONS IS ANSWERED YES—YOU MUST ATTACH DOCUMENTATION.

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 Non-Resident license Applications, I certify that I am licensed and in good standing in my home state/resident state for the lines of authority requested from the non-resident state.

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.