Form Fin506 – Fill Out and Use This PDF

FIN506-SV | 0421

Application for individual agent license

Applicant General Information Guide begins on Page 11.

Use this application if you are not able to apply online and are required to pass a qualifying examination through Pearson VUE, except for Home Office Salaried Employee (HOSE).

All applications are subject to further review. Answering “yes” to a screening question might extend processing times. Failure to disclose criminal history information could result in denial of license.

Part I – To be completed by all individual applicants (Choose only one license type)

Those who want to apply for more than one license type must submit a separate application and fee for each type. Only the following applications can be submitted using this form. All other license applications must be submitted electronically.

License Types (Check only one box):

License Fees: Unless otherwise indicated, fees are $50 per license type. A $75 fee is required for

alicense that has been expired for more than 90 days but less than one year (TIC Section 4003.007). Make check or money order payable to the Texas Department of Insurance. All license fees are nonrefundable and nontransferable. (TIC Section 4001.006)

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Information about you - Please read carefully and provide all requested information.

1Your full legal name – nicknames and abbreviations are not acceptable.

_______________________________________________________________________________________________________

First name

Middle name

Last name

Suffix

2Your Social Security number, date of birth, and daytime phone number – The application cannot be processed without this information. Disclosure of Social Security number is required by Texas Family Code Section 231.302.

Social Security number _______________________________________________________________________________________

Date of birth (MM/DD/YY) _________________________

Daytime phone number ____________________

3Mailing address (required – This is the address of record with TDI; TDI correspondence will be mailed to this address)

Street address of P.O. box ___________________________________________________________________________

City __________________________________________ State _________________________ ZIP ____________________

4Legal resident address (required – This is the address where you live and establishes state of residency)

Street address _______________________________________________________________________________________

City __________________________________________ State _________________________ ZIP ____________________

5Official business address (required – This must be your primary office address where you will maintain business records of Texas insurance transactions. Your resident address must be used if you do not have a business address.)

Street address ______________________________________________________________________________________

City __________________________________________ State _________________________ ZIP ____________________

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6Your email address (required – Email is the preferred method used for TDI communications)

_______________________________________________________________

7Excluding traffic violations and first offense DWI:

A. Do you currently have any pending misdemeanor or felony charges (by indictment, information, or any other instrument) filed against you in Texas, in any other state, or by the federal government?

B. Have you ever been convicted of any misdemeanor or felony offense in Texas, in any other state, or by the federal government?

C. Have you ever had adjudication deferred on any misdemeanor or felony charge or offense in Texas, in any other state, or by the federal government?

D. Have you ever served any period of probation for any misdemeanor or felony offense in Texas, in any other state, or by the federal government?

E. Have you ever been subject to charges referred to in a special or general court-martial?

F. Are you under investigation or charged with an offense under the Uniform Code of Military Justice (UCMJ)?

If you answer “Yes” to any of questions 7 a–f, you must submit original certified copies of the charging document, indictment, information, or any other charging document, judgment of conviction or deferred adjudication order, probation order, order terminating probation, community supervision or parole certificate for each and every offense. If the court states it no longer has the records, please have the court provide us with a letter on its letterhead stating that fact. If you were arrested only and not prosecuted, provide a records search from the appropriate jurisdiction indicating a final disposition. You must submit a statement describing the circumstances leading to the offenses. You must include your age at the times of the offenses. You may provide letters of recommendations from any persons in contact with you that are aware of your criminal past.

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8Have you ever applied for a letter of consent, as required under Section 18 U.S.C. 1033(e), from any insurance regulatory official from Texas or any other state?

If you answer “Yes,” we will not process the application until you provide us with full details of the outcome of that proceeding and all supporting documents.

If you answer “No,” and you have been convicted of any criminal felony involving dishonesty or breach of trust, or an offense under Section 18 U.S.C. 1033, we will not process the application until you provide us with a signed and notarized request for written consent with all supporting documentation.

9Have you or has any corporation, partnership, association or firm in which you were a director, officer, shareholder, manager, member or partner, ever been the subject of an administrative or legal action filed by Texas or any other insurance department, or financial regulatory agency, or of an action filed on behalf of Texas or any other state or by the federal government based on alleged violations of state or federal insurance, securities or financial regulatory laws that you have not previously reported to the Texas Department of Insurance?

If you answer “Yes,” we will not process the application until you have provided us with full details of the administrative or legal action.

10Are you indebted to any policyholder, insurance or reinsurance company, insurance agency, general agent, managing general agency, premium finance company or court appointed liquidator for premiums collected or commissions retained, or have any claims or judgments been filed against you for retaining premiums or commissions?

If you answer “Yes,” we will not process the application until you provide us with full details of the indebtedness.

11Have you ever had an agency contract or company appointment cancelled for cause (for example, misrepresentation, misappropriation, etc.)?

If you answer “Yes,” we will not process the application until you’ve provided us with full details. Cancellation for cause does not include cancellations due to license expiration (nonrenewal).

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12Do you currently hold any insurance agent license, adjuster or public insurance adjuster license in any state other than Texas, or have you held any insurance agent license, adjuster or public insurance adjuster license in any state other than Texas within the last five years?

If you answer “Yes,” you must provide the following:

Applicants who hold or have held a resident license in another state within the previous five years from the date of this application will be verified by NIPR Producer Database.

13This application is for a license I previously held that is expired for more than 90 days but less than one year. I will attach the required $75 license fee. (TIC Section 4003.007)

14Do you have a child support obligation in arrearage?

	No	Yes
	If you answered “Yes,” you must answer a, b, and c:
A. How many months are you in arrearage? ____________
B.	Are you currently subject to and in compliance with any repayment agreement?
	No	Yes
C.	Are you the subject of a child support-related subpoena or warrant?
	No	Yes

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Part III – Notice of appointment To be completed by a sponsor on behalf of those applying for a Full-Time Home Office Salaried Employee’s (HOSE) registration.

Notice of appointment for HOSE applicants

Your full legal name – nicknames and abbreviations are not acceptable.

_______________________________________________________________________________________________________

First name

Middle name

Last name

Suffix

Enter sponsoring company information.

Name of sponsoring insurance company appointing a HOSE applicant:

_______________________________________________________

Appointing company name (group names are not acceptable)

__________________________________

NAIC number of appointing company

The appointing official must read and sign the following statements:

This is to certify that the applicant named on this form is appointed to act as an agent for this company in Texas subject to the applicant qualifying for a license. If this appointment is terminated or canceled, the Texas Department of Insurance will be notified immediately.

This applicant meets the requirements of the Texas Insurance Code and TDI rules and regulations for the type of license the applicant has applied for.

I acknowledge my responsibility for ensuring that the applicant receives training, as required by the TIC.

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Before me,	, on this day personally appeared

Printed name of notary public

, known to me or proved to me

Printed full legal name of applicant

on the oath of

Printed name of witness known to notary public

or through

(Description of identity card or other document)

to be the person whose name is subscribed to the foregoing instrument and acknowledged to me that he or she executed the same for the purposes and consideration therein expressed.

Given under my hand and seal of office this		day of		, A.D. 20		.

(Notary Seal)

(Notary public signature)

Notary public, state of ______________________

Send completed application, any other required documents, and a check or money order made payable to the

Texas Department of Insurance.

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General Information Guide

	Parts required to be completed
License type	PART	PART	PART	PART	PART
	I	II	III	IV	V
Life & Health Insurance Counselor (Chapter 4052)
Full-Time Home Office Salaried Employee (Section
Insurance Service Representative (Section 4051.151)
Risk Manager (Chapter 4153)

Mail the completed application, fees, and required attachments by mail:

Via USPS send to:

Agent and Adjuster Licensing, MC CO-AAL

Texas Department of Insurance

PO Box 12069

Austin, TX 78711-2069

Via UPS and FedEX send to:

Texas Department of Insurance Attn: Lockbox Department 208 E. 10th St, MC- CO AAL Austin, TX 78711

Obtaining a Printed License: You can print a copy of your Texas Department of Insurance license at www.sircon.com/Texas. A fee will be required. You will need your license number to print the license; you can get your license number via a search at https://txapps.texas.gov/NASApp/tdi/TdiARManager.

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Notice language for insurance forms: Your rights: You can request information we have about you by emailing

OpenRecords@tdi.texas.gov or writing to: Public Information Coordinator, Texas Department of Insurance, PO Box 12030 (mail code GC-ORO) Austin, Texas 78711-2030. You also have the right to ask that we fix information we have about you that is wrong. To ask for a correction, send (1) your name, mailing address, and your phone number, (2) details about what needs to be fixed, and (3) the reason or proof showing why the information is wrong. Send this by email to RecordCorrections@tdi.texas.gov or by mail to: Record Correction Request, Texas Department of Insurance, PO Box 12030 (mail code CO-AAL-CC), Austin, Texas 78711-2030.

Fees: 28 TAC Sections 19.801-19.802: All fees are nonrefundable and nontransferable. Make check or money order payable to the Texas Department of Insurance.

Applicants with expired licenses: If a person’s license has been expired for more than 90 days but less than one year, the person may not renew the license, but is entitled to a new license without taking the applicable examination if the person submits to TDI a new application, the license fee, and an additional fee equal to one- half of the license fee. If a person’s license has been expired for one year or more, the person may obtain a new license by submitting to reexamination, if examination is required for original issuance of the license, and by complying with the requirements and procedures for obtaining an original license.

Addresses: The mailing address provided in Part I, No. 3 must be your permanent mailing address and is the address of record to which official correspondence, forms, notices and other information will be sent. The applicant's current mailing address is presumed to be the address on the most recent license renewal for an existing license or on this license application form, whichever is latest. This address will be considered the applicant's or agent’s last known address for notice to the applicant or agent by TDI. The legal resident address is the address where you currently live. The legal resident address is used to determine the state of residence for licensing purposes.

Address changes: You must report address changes to TDI within 30 days as required by TIC Sections 4001.252 and 4003.009. Individual licensees who want to submit an address change within the same state should submit the request online through NIPR Contact Change Request or Producer Edge Account. All other change requests should be submitted on the Licensee Name/Address Change Request (TDI Form FIN533) to TDI. There is no fee for this change request. Please review the instructions on the form carefully to ensure that all necessary information is included, and that any delivery or mailing instructions are followed.

Texas-licensed nonresident individuals changing residency to Texas:

Processing a change from a nonresident licensee status to a resident licensee status requires a completed

Application for Residency Change to Texas (TDI Form FIN594). All address change request forms must be dated and signed by the license holder, and must include any of the required items listed in the appropriate form.

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Fingerprint requirements and instructions:

Fingerprinting: The fingerprint requirement is authorized in TIC Sections 801.056, 4001.103 and by 28 TAC Sections 1.501 and 1.503-1.509.

Applicants claiming exemption from the fingerprint requirement based on 28 TAC Section 1.504(b) must provide information on the type of license application or TDI filing with which the fingerprints were submitted and the date the fingerprints were submitted to TDI.

TDI encourages applicants to use electronic fingerprinting through approved vendors, as authorized under the rule. Electronic fingerprinting is fast and accurate, and in most cases will avoid potential delays in the processing of your submission.

TDI no longer accepts fingerprint cards.

For detailed information about fingerprint requirements and fee requirements visit

https://www.tdi.texas.gov/agent/fingerprint-instructions.html

TDI cannot process an application until it receives a criminal history report from the Texas Department of Public Safety and the FBI for applicants required to provide a fingerprint receipt.

References: You may view the Texas Insurance Code at https://statutes.capitol.texas.gov/?link=IN and the

Texas Administrative Code at http://texreg.sos.state.tx.us/public/readtac$ext.viewtac.

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