Florida Resident Application Questionnaire

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Madison Caldwell
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1 Florida Resident Application Questionnaire Please return completed and signed form to: FLORIDA RLC Primerica Regional Licensing Center 2507 Callaway Road, Suite 206, Tallahassee, FL Phone: (850) ~~ Toll-Free Fax: (800) ~~ 1) Social Security Number:* *te: You must have a valid Social Security Number (SSN) on your license application. Tax ID numbers and Individual Tax Identification Numbers (ITINs) will not be accepted. 2) Date of Birth (mm/dd/yyyy): 3) Legal* Name: First Middle Last Suffix *te: You are REQUIRED to have the name listed above match the name on the government issued signature and photo ID (e.g., driver's license) that you use at the testing site. 4) Sex: Male Female 5) Ethnic Identification: White/n-Hispanic Black/n-Hispanic Hispanic Asian/Pacific Islander American Indian/Alaska Native Other 6) Native Language: English Spanish Other 7) Select your highest level of Education: Less than High School High School Diploma or GED Some College 4-Year College Degree Advanced Degree 8) Home Street Address: City: County: State: Zip: 9) Home Telephone Number (include area code): ( ) 10) Address* *te: Without your correct address, this division cannot keep you updated when laws and rules change that affect your license. 11) RVP Street Address: RVP City: County: State: Zip: 12) RVP Telephone Number (include area code): ( ) Preferred Mailing Address Home Business Other* *If Other, please provide address: Street Address City: County: State: Zip Rev. 06/2010, Page 1 of 8

2 Questions 13-27: The Applicant must read the following very carefully and answer every question: Any yes answers require appropriate documentation be sent to the RLC with the Questionnaire. A listing of Appropriate Documentation is found at the end of this Questionnaire. 13) On the following screens you will be asked a series of background questions. If you have ever entered a plea of guilty, nolo contendere (no contest), or been convicted or found guilty of a felony crime, you are required to give a YES answer, whether or not adjudication of guilt was withheld. Here is a link to the appropriate Florida Administrative Code in regards to the effect of criminal history on a license application: Florida Administrative Code. If you have been so convicted or have entered one of the pleas above and fail to provide a YES answer, your application may be denied. If you are unsure about how to answer questions regarding your criminal history, you should consult an attorney or review your court records prior to answering. If you have additional questions please contact the Bureau of Licensing at (850) I understand the consequences of not providing correct information on this application. 14) I affirm that I understand I must maintain a valid address with the Florida Department of Financial Services. 15) Are you currently on probation for any legal action other than DUI or participating in a pretrial intervention program or any other diversion program? 16) Are there currently pending against you or any entity you control any criminal, administrative or civil charges in any state or federal court anywhere in the United States or its possessions or any other country? 17) In the past 12 months, have you been arrested, indicted, or had any information filed against you or been otherwise charged with a crime by any law enforcement authority anywhere in the United States or its possessions or any other country? 18) Have you ever been convicted, found guilty, or pled guilty or nolo contendre (no contest) to felony under the laws of any municipality, county, state, territory or country, whether or not adjudication was withheld or a judgment of conviction was entered? 19) Has a judgment ever been obtained or is there currently pending any type of civil action as it relates to insurance against you individually or against any entity in which you are or were an officer, director, partner, or owner? 20) Has any insurance agency that you are now or have you ever been an officer, partner, joint venturer, shareholder, or owner, filed for protection under the Bankruptcy Act or been the subject of a petition for involuntary bankruptcy? (This does not include personal bankruptcy.) 21) Has any Company ever refused to bond you? 22) Have you ever been refused a securities, real estate broker, or other license by a state agency or a public authority in any jurisdiction? 23) Have you ever had an application for a license declined or denied by this or any other insurance regulatory body? Rev. 06/2010, Page 2 of 8

3 24) Have you ever had any professional license subjected to any of the following actions by any state agency or public authority or any other regulatory authority in any jurisdiction? Revocation of an insurance license in Florida less than two years ago Revocation of an non-insurance license in Florida less than two years ago Revocation in another state at any time or in Florida more than two years ago Suspension Placed on probation Administrative fine or penalty levied Cease and desist order entered 25) Have you ever had any insurance agency contract terminated by an insurance company or managing general agent for any alleged cause? 26) Are you currently indebted to any insurer, managing general agent, agent, or premium finance company? 27) Do you have a child support obligation in arrearage? If you answer yes, please submit documentation that child support obligation/arrearage has been satisfied or that you are on a court supervised payment plan. You may provide a court-ordered payment schedule, wage garnishment letter or income deduction order. If you answer yes, by how many months are you in arrearage? 28) Have you filed a set of fingerprints with the Department s Bureau of Licensing within the past 12 months? 29) Are you applying for a temporary or a permanent license? Temporary Permanent 30) TYPE OF LICENSE(S) for which you are applying: 02-15* Resident Life Including Variable Annuity & Health Insurance Agent *If you completed the UCanPass online course that included Health, or if you completed the classroom Life course and the Health portion of the UCANPASS online course, you are qualified to take the 2-15 Life, Var. Annuity & Health exam ** Resident Life Including Variable Annuity Insurance Agent **If you completed the Primerica Education classroom prelicensing course, you are qualified to apply for the 2-14 Life and Variable Annuity Exam Legal Expense Agent 31) a) Are you a United States citizen? b) Are you a legal alien with work authorization?* *te: If you answer YES to Question 31b, you must attach the following to this Questionnaire: 1. Legible copy of front and back of Permanent Resident Alien Card (Green Card) and legible copy of Social Security Card ~ OR ~ 2. Visa and Work Authorization and legible copy of Social Security Card 32) Are you an employee of the United States Veterans Administration or its State Service Office? * *te: If you are an employee of the USVA or its State Service Office, you are disqualified from getting a Life Insurance License in Florida. 33) Are you a funeral director, direct disposer or an employee or representative thereof, or do you have an office in or in connection with a funeral establishment? Rev. 06/2010, Page 3 of 8

4 * *te: If you are a funeral director, the Florida Department of Financial Services must issue a Certificate of Authority to your funeral home. In addition, you are limited to selling a maximum of $10,000 face value policy per client. 34) Are you applying for a license in order to place insurance PRINCIPALLY on your own life or interests or that of members of your family? 35) Are you applying for a license in order to place insurance PRINCIPALLY on an officer, director, stockholder, partner or employee of a business in which you or a member of your family is engaged? 36) Are you applying for a license for the PRIMARY purpose of writing insurance covering a debtor of a firm, association, or corporation in which you are an officer, director, stockholder, partner or employee? 37) If you have held a license in another state in prior years, you may be exempt from the exam. Have you held a license in another state for a minimum of one (1) year immediately proceeding the date you became a resident of this state and have not been a resident of Florida for more than 90 days from today's date. 38) Have you held a resident insurance license in another state during the last three years? 39) Do you have the Chartered Life Underwriter (CLU) designation? * *te: If yes, and you have been engaged in the insurance business in the last four years, you are exempt from the prelicensing course as well as the life insurance exam once you submit (as proof) an original letter from the institute that awarded that designation. 40) Did you successfully complete a 40-hour pre-licensing course or a correspondence course approved by the Department within the last four years? 41) Identify the following: Name of Pre-License Course: Completion Date of Course: Primerica Prelicensing Life USA L/H Variable ucanpass Online Rev. 06/2010, Page 4 of 8

5 Applicant Authorization Statement I authorize and direct Primerica Life Insurance Company ( the Company ) or its designated representative to submit electronically to the Florida Department of Financial Services all the information I have provided herein, together with other information from my Independent Business Application. I shall be liable for and agree to indemnify and hold the Company harmless for any and all harm related to or arising from the application, its submission and transmission, including but not limited to harm resulting from any incomplete or false answers made by me. Signature of Applicant Date (mm/dd/yy) Rev. 06/2010, Page 5 of 8

6 Applicant Affirmation Statement Where required by law, I hereby name and appoint the Chief Financial Officer of the State of Florida my attorney to receive service of legal process issued against me, upon causes of action arising within the State of Florida out of transactions under my Florida license; that this appointment shall constitute effective legal service upon me as long as there may be any cause of action against me arising out of insurance transactions within the State of Florida. ( ; , F.S.) Whoever knowingly makes a false statement in writing with the intent to mislead a public servant in the performance of his/her official duty shall be guilty of a misdemeanor of the second degree. Under penalties of perjury, I declare that I have read the foregoing application for license and that the facts stated in it are true. I understand that misrepresentation of any fact required to be disclosed through this application is a violation of the Florida Insurance and Administrative Codes and may result in the denial of my application and/or the revocation of my insurance licenses(s). I agree to the above statement. Printed Name of Applicant Solution Number Signature of Applicant Date (mm/dd/yy) Rev. 06/2010, Page 6 of 8

7 Florida Appropriate Documentation NOTE: If Appropriate Documentation is requested on Recruit Manager, the Applicant must send the RLC all documents listed for each applicable question. Reference Form: FL Resident App. Questionnaire Number/Revision Date: 06/2010 te: Once the state department has reviewed all documentation submitted, additional information or supporting documentation may be requested regarding incidents reported in this application. Question Signed dated statement from the Applicant affirming that he/she understands that a valid address must be maintained with the Florida Department of Financial Services. Questions 15, 16, 17, 18, and Signed dated statement from the Applicant explaining the circumstances of each incident and current status (statement must include an original signature), 2. Original certified charging document and any other relevant documents, 3. Original certified official document which demonstrates the resolution of the charges or any final judgment, any other relevant documents, and 4. Current Special Registration Review (SRR) Form, with RVP and OSJ signatures (if not previously Q20 INSURANCE RELATED DEBT 1. Signed dated statement from the Applicant summarizing the details of the indebtedness and arrangements for repayment (statement must include an original signature), 2. Letter from entity showing current status, and BANKRUPTCY Pending Case (Open) 1. Signed dated statement from the Applicant summarizing the details of the indebtedness and arrangements for repayment, and/or type and location of bankruptcy (statement must include an original signature), 2. Current Trustees report (full report), 3. Schedules D, E and F, and 4. Current Special Registration Review (SRR) Form, with RVP and OSJ signatures (if not previously Discharged (Closed) 1. Signed dated statement from the Applicant summarizing the details of the indebtedness and arrangements for repayment, and/or type and location of bankruptcy (statement must include an original signature), 2. Discharge of Debtor, and Dismissed (Closed Incomplete) 1. Signed dated statement from the Applicant summarizing the details of the indebtedness, arrangements for repayment, type and location of bankruptcy and reason bankruptcy was dismissed (statement must include an original signature), 2. Court documents that include: Date filed, Date dismissed, Amount owed at time of dismissal, Current status, and Rev. 06/2010, Page 7 of 8

8 Q21 1. Signed dated statement from the Applicant that includes your current status, summarizes the details of the refusal and explains why you feel this incident should not prevent you from receiving an insurance license (statement must include an original signature), 2. Copy of the denial letter and certified copies of all other relevant documents, and Q22 and Q23 1. Signed dated statement from the Applicant that includes your current status, summarizes the details of each incident and explains why you feel this incident should not prevent you from receiving an insurance license (statement must include an original signature), 2. Original certified relevant documents, and Q24 1. Signed dated statement from the Applicant identifying the type of license and explaining the circumstances of each incident and current status (statement must include an original signature), 2. Original certified tice of Hearing or other document that states the charges and allegations and any other relevant documents, 3. Original certified official document which demonstrates the resolution of the charges or any final judgment, any other relevant documents, and 4. Current Special Registration Review (SRR) Form, with RVP and OSJ signatures (if not previously Q25 1. Signed dated statement from the Applicant that includes your current status, summarizes the details of each incident and explains why you feel this incident should not prevent you from receiving an insurance license (statement must include an original signature), 2. Original certified relevant documents, and Q26 Q27 INSURANCE RELATED DEBT 1. Signed dated statement from the Applicant summarizing the details of the indebtedness and arrangements for repayment (statement must include an original signature), 2. Letter from entity showing current status, and 1. Signed dated statement from the Applicant providing full details including number of months in arrearage and repayment plan (statement must include an original signature), 2. Original certified court documents showing amount in arrears (if applicable), and 06/21/2010 Rev. 06/2010, Page 8 of 8

Florida Resident Application Questionnaire

Florida Resident Application Questionnaire Please return completed and signed form to: FLORIDA RLC Primerica Regional Licensing Center 2507 Callaway Road, Suite 206, Tallahassee, FL 32303 Phone: (850)