Form Fis 0202 – Fill Out and Use This PDF

FIS 0202 (4/08) Office of Financial and Insurance Regulation

Michigan Application for Resident Business Entity Insurance License

(Please Print or Type)

1	FEIN										2 Business Entity Name														3	Incorporation/Formation Date
																									(month) ___(day) ___(year) _____
4	If assigned, National					Producer Number (NP#)												5 If applicable, NASD Firm Central Registration Depository (CRD) Number
6	List any other assumed, fictitious, alias or trade names under which you are doing																			7	State of Domicile	8 Country of Domicile
business or intend to do business.
9	Is the business entity affiliated with a financial institution/bank?																		10	Financial Institution/bank FEIN and name
Yes					No					If yes, complete item 10
11	Business Address (Physical Street)																			12	Business Address (Line Two)
13	City												14	State or Province						15	Zip					16 Foreign Country
17	Phone Number										18 Extension			19 Fax Number						20 Business Web Site Address						21 Business E-Mail Address *Required*
	(		)		-									(	)		-
22	Maiing Address (Physical Street or PO Box) ** Complete Mailing Address is Required **																			23	Mailing Address (Line Two)
24	City												25	State or Province						26	Zip					27 Foreign Country
															Designated/Responsible Licensed Producer
28	Identify at least one Designated/Responsible Licensed Producer:
SSN					-	-				NP#_________________ Name
SSN					-	-				NP#_________________ Name
SSN					-	-				NP#_________________ Name
SSN					-	-				NP#_________________ Name
															Owners, Partners, Officers and Directors
29	Identify all owners, partners, officers and directors of the business entity, or members or managers of a limited liability company:
SSN/FEIN					-	-						Name											Title
SSN/FEIN					-	-						Name											Title
SSN/FEIN					-	-						Name											Title
SSN/FEIN					-	-						Name											Title
SSN/FEIN					-	-						Name											Title
SSN/FEIN					-	-						Name											Title
SSN/FEIN					-	-						Name											Title
SSN/FEIN					-	-						Name											Title
SSN/FEIN					-	-						Name											Title
SSN/FEIN					-	-						Name											Title
SSN/FEIN					-	-						Name											Title
SSN/FEIN					-	-						Name											Title

FIS 0202 (4/08) Page 3 of 3

6. Has the business entity or any owner, partner, officer or director, or member or manager if a limited liability company, ever had an insurance agencyYes ___ No___

contract or any other business relationship with an insurance company terminated for any alleged misconduct?

If you answer yes, you must attach to this application:

a)a written statement summarizing the details of each incident and explaining why you feel this incident should not prevent you from receiving an insurance license, and

b)certified copies of all relevant documents.

7.	Is this agency a “motor vehicle dealer-related agency”?	Yes ___ No___
	If yes, enter the name and FEIN of the dealership. Indicate Dealership by entering “Dealership” as the Title.

Applicants Certificate and Attestation

32 The undersigned owner, partner, officer or director of the business entity hereby certifies, under penalty of perjury, that:

1.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 or limited liability company to civil or criminal penalties.

2.Where required by law, the business entity or limited liability company hereby designates the Commissioner, Director or Superintendent of Insurance, or an appropriate representative in each jurisdiction for which this application is made to be its agent for service of process regarding all insurance matters in the respective jurisdiction and agree that service upon the Commissioner or Director of that jurisdiction is of the same legal force and validity as personal service upon the business entity.

3.The business entity or limited liability company grants permission to the Commissioner or Director of Insurance in each jurisdiction for which this application is made to verify any information supplied with any federal, state or local government agency, current or former employer or insurance company.

4.Every owner, partner, officer or director of the business entity, or member or manager of a limited liability company, 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.

5.I authorize 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.

6.I acknowledge that I understand and comply with the insurance laws and regulations of the jurisdictions to which I am applying for licensure/registration.

7.If required, I have received a Certificate of Good Standing from the jurisdiction's Secretary of State in which I am applying.

8.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.

Attachments

33The following attachments must accompany the application otherwise the application may be returned unprocessed or be considered deficient. Corporations need to attach Articles of Incorporation.

Partnerships, Limited Liability Partnerships and Sole Proprietorships need to attach Creation Papers. Limited Liability Companies need to attach Articles of Organization

Must be signed by an officer, director, principal or partner of the business entity, or member or manager if a limited liability company:

_____________________________________

Month	Day	Year	Signature
			_______________________________________________________
			Typed or Printed Name
			_______________________________________________________
			Title
			_______________________________________________________
			Social Security Number
			_______________________________________________________
			Address
			_______________________________________________________
			City	State	Zip

_______________________________________________________

Authorized by PA 218 of 1956 as amended. Failure to properly complete this application may result in a rejection of your application, or a compliance action including revocation, against any Michigan licenses issued to you by the Office of Financial and Insurance Regulation.