Nation Motor Club, LLC. 800 Yamato Road, Suite 100, Boca Raton, FL Tel: Fax: California

Transcription

1 Nation Motor Club, LLC. 800 Yamato Road, Suite 100, Boca Raton, FL Tel: Fax: California Representatives/Producers currently holding Fire & Casualty or Motor Club licenses: Submit clear copy of license Individual - Action tice of Appointment (LIC A) Business - Business Entity Endorsement (LIC-411-8A) $58 ($29 Individual appointment + $29 Business Entity appointment) Representatives/Producers who DO NOT currently hold Fire & Casualty or Motor Club licenses will need to do the following: Resident Producers: *Residents can apply for either Fire & Casualty or Motor Club licensure* Online application through the FLASH system or you may submit to Nation Motor Club, the Individual Application for Insurance License (441-9) and the Business Entity Application for Insurance License (441-11) $170 - Individual licensing fee $170 - Business Entity licensing fee For Fire & Casualty license there will be an examination fee of $50 For Fire & Casualty license the representative/producer must complete the Live Scan Service Request form and submit to the CDI vendor at the examination site, along with a $58.30 fee Individual - Action tice of Appointment (LIC A) Business - Business Entity Endorsement (LIC-411-8A) $58 ($29 Individual appointment + $29 Business Entity appointment) n-resident Producers: *n-residents can only apply for the Fire & Casualty license* Online application through the FLASH system or you may submit to Nation Motor Club, the Individual Application for Insurance License (441-9) and the Business Entity Application for Insurance License (441-11) $170 - Individual licensing fee $170 - Business Entity licensing fee Revised 7/14/2017 T.D 1

2 Submit a clear copy of resident license or certification from domicile state Must submit fingerprint impression card taken by a law enforcement agency - Police or Sheriff Department standard fingerprint card - please enclose a check for $58.30 (fingerprint fees) made payable to Accurate Biometrics. Please note requirement on fingerprint card. You must enter A0042 in the space designated for ORI and you must enter 1000 in the space designated for OCA. This must be mailed to Accurate Biometrics at 455 Capitol Mall, Suite 233, Sacramento, CA REPRESENTATIVES/PRODUCERS FROM THE FOLLOWING STATES ARE NOT REQUIRED TO SUBMIT FINGERPRINTS: Alaska, Arizona, Florida, Georgia, Idaho, Louisiana, Montana, New Jersey, Nevada, Ohio, Oregon, Pennsylvania, Tennessee, Texas, Utah and Washington Individual - Action tice of Appointment (LIC A) Business - Business Entity Endorsement (LIC-411-8A) $58 ($29 Individual appointment + $29 Business Entity appointment) If you have any questions, please contact your Marketing Representative or our Licensing & Compliance Department at ext. 336 Make all checks payable to Nation Safe Drivers and mail the check and completed forms to: Nation Safe Drivers Attention: Licensing & Compliance Department 800 Yamato Road, Suite 100 Boca Raton, FL Revised 7/14/2017 T.D 2

3 State of California Business Entity Application for Insurance License LIC Rev 5/ Business Entity Types (Check one only) Department of Insurance Department Use Only Corporation General Partnership Limited Liability Company 2. License Type Limited Liability Partnership/Limited Partnership nprofit Corporation Unincorporated Association License Life-Only Agent (LO) Variable Contract Authority (VC) Accident and Health Agent (AH) Property Broker-Agent (PR) Casualty Broker-Agent (CA) Personal Lines Broker-Agent (PL) Limited Line Automobile Insurance Agent (AU) Credit Insurance Agent (CI) Motor Club Agent (MC) Self-Service Storage Agent (SS) Portable Electronics Insurance Agent (PE) Surplus Line Broker (SL) Special Lines Surplus Line Broker (SP) Life & Disability Analyst (LA) Cargo Shipper s Agent (CS) Vehicle Service Contract Provider VS Rental Car Agent (RC) Travel Insurance Agent (TA) 3. Business Entity Name 4. Federal Employer Identification Number 5. Name Approval Confirmation # 6. State of Incorporation 7. Business address (PO Box not acceptable) 8. Business phone number ( ) 11. Mailing Address (PO Box is acceptable) 9. Business fax number ( ) 10. Business Address and Business Entity Website Address 12. Fictitious names a. Does the business entity intend to use a fictitious (DBA) name? If yes, list such name: (This name must be approved by the Department prior to use.) b. Is the business entity now or has it ever used any name other than shown? If yes, list names, dates and reason(s) used: 13. Business Entity Information: Is this business entity engaged in any business or activity other than insurance? If yes, answer the following: a. What is the nature of this other business or activity? b. What percentage of the business entity s net income will be derived from this other business or activity? Important: Business entity applicants engaged in business other than insurance are cautioned to review the laws governing such other business to ensure that the transacting of insurance is not incompatible under such laws. 14. Is the business entity an insurer? 15. Does the Business Entity hold an insurance license and is the Business Entity adding a line of authority? Or has the Business Entity ever held an insurnace license as a resident in any state, including the state of California? If yes, complete the following: (attach a separate sheet if needed) Type of License and License Number State or Province Date License Held Is License In Force?

4 16. Life-Only Agent License Applicants only: Does the business entity intend to act as a Variable Contract Agent? Any business entity intending to act as a Variable Contract Agent must have at least one Designated/Responsible Licensed Producer authorized as a Variable Contract Agent. 17. Designated/Responsible Licensed Producer (s) Identify all Designated/Responsible Licensed Producers* (Attach a separate sheet if needed) Name SSN** License # Name SSN** License # Name SSN** License # Name SSN** License # *te: If you are not a current California licensee (resident or non-resident), a separate application form must be completed by each person name above. 18. Business Entity Disclosure: Identify all partners, members, officers, directors, managers, controlling persons and any shareholders owning 10% or more interest in the business entity. (Attach separate sheet if more space is needed) 19. Controlling Person(s): (Attach separate sheet if more space is needed) A "Controlling Person" as defined in section (b) is the following: If you are listing a individual, corporation, partnership, limited liability company, limited partnership, holding company or trust in section #18, then you must identify the Controlling Person or Persons, including the president, chief executive officer, chairman of the board, those people that own 10% or more of the stock and any other person who directly or indirectly possess the power to control the affairs of the business entity. **Disclosure of your U. S. social security number is mandatory pursuant to Insurance Code section , Cal. Civil Code, ; Cal. Family Code, 17520(d); and Federal Privacy Act of 1974, 7(a) (2) (B) and 7(b). The social security number will be used primarily for purposes of processing your application, including conducting any necessary investigation into your background. If you fail to disclose your social security number, your application will not be reviewed. An individual has a right of access to certain records containing personal information pertaining to that individual. Individuals may obtain information regarding the location of their records by contacting the Bureau Chief, Producer Licensing Bureau, California Department of Insurance by phone ( ) or by mail, to the following address: 320 Capitol Mall, Sacramento CA Page 2 of 6 LIC (Rev 5/2014)

5 20. Surplus Line and/or Special Lines Surplus Line Applicants only: tification of your filing for a Surplus Line Brokers license will be forwarded to the Surplus Line Association of California, who will notify you as to their filing rules (California Code of Regulations, Title 10, Section 2172). List names of all insurers not admitted to California with whom arrangements have been made to accept or who are considering the acceptance of surplus line business offered by the business entity: Surplus Line or Special Lines Surplus Lines Business Entity Endorsement Authorization List name of each person applying to transact under the authority of this license type. Name SSN** License # Name SSN** License # Name SSN** License # Background Questions If your fail to fully disclose any information that is required or if you make a false statement, your application may be denied. Federal law (18 U.S.C. 1033) prohibits anyone who has been convicted of a felony involving dishonesty or a breach of trust or who has been convicted of any violation of 18 U.S.C and 1034 from engaging in the business of insurance unless they have obtained the written consent of the Insurance Commissioner. It is a violation of this statute to engage in the business of insurance without the Commissioner s written consent. Further, it is a criminal offense for any person to willfully employ, or willfully permit, such "prohibited persons" to engage in the business of insurance without the required written consent. A "Prohibited Person" may be an officer, director or employee of an insurance agency or an insurance company, an agent, solicitor, broker, consultant, third party administrator, managing general agent, or subcontractor representing an insurance agency or insurance company who engages in or transacts the business of insurance. If you have a Prohibited Person in your organization that meets this criteria and has been convicted of a felony involving dishonesty or a breach of trust or a violation of 18 U.S.C and 1034, then the Prohibited Person must obtain written consent prior to filing this application. DO NOT SUBMIT THIS APPLICATION UNTIL THE PROHIBITED PERSON HAS FILED FOR WRITTEN CONSENT FROM THE COMMISSIONER. If they have received consent, a copy of their consent letter must be attached to this application. If you are applying for a non-resident license, attach a copy of the written consent letter issued by their home state. Instructions to apply for the written consent are available on the CDI s Web site at Has the business entity or any of its partners, members, controlling persons, officers, directors, managers, or any shareholders owning 10% or more interest in the business entity, ever been convicted of, or is the business entity or, any partner, member, controlling person officer, director, manager or any shareholders owning 10% or more interest in the business entity currently charged with, committing a crime, whether or not adjudication was withheld? Crime includes a felony, a misdemeanor or military offense. Convicted includes, but is not limited to, having been found guilty by a verdict of a judge or jury, having entered a plea of nolo contendere, no contest, having had any charge expunged, dismissed or plea withdrawn pursuant to Penal Code Section , or having been given probation, a suspended sentence or a fine. You may exclude traffic citations and juvenile offenses tried in juvenile court. You should answer "yes" if you have been convicted of a felony or a misdemeanor including driving offenses such as, but not limited to reckless driving, driving under the influence and driving with a suspended license, whether or not you spent any time in jail, and whether or not you believe the conviction has been removed from your record. If you answer yes, you must attach to this application: a) a written statement with original signature explaining the circumstances of each incident, b) a certified copy of the charging document, and a certified copy of the official document which demonstrates the resolution of the charges or any final judgment. *Disclosure of your U. S. social security number is mandatory pursuant to Insurance Code section , Cal. Civil Code, ; Cal. Family Code, 17520(d); and Federal Privacy Act of 1974, 7(a) (2) (B) and 7(b). The social security number will be used primarily for purposes of processing your application, including conducting any necessary investigation into your background. If you fail to disclose your social security number, your application will not be reviewed. An individual has a right of access to certain records containing personal information pertaining to that individual. Individuals may obtain information regarding the location of their records by contacting the Bureau Chief, Producer Licensing Bureau, California Department of Insurance by phone ( ) or by mail, to the following address: 320 Capitol Mall, Sacramento CA Page 3 of 6 LIC (Rev 5/2014)

6 Background Information continued If your fail to fully disclose any information that is required or if you make a false statement, your application may be denied. 22. Has the business entity or any of its partners, members, controlling persons, officers, directors, managers or any shareholders owning 10% or more interest in the business entity, ever been involved in an administrative proceeding regarding any professional or occupational license? Involved means having a license censured, suspended, revoked, canceled, terminated or, being assessed a fine, placed on probation or surrendering a license to resolve an administrative action. Involved also means being named as a party to an administrative or arbitration proceeding which is related to a professional or occupational license. Involved also means having a license application denied or the act of withdrawing an application to avoid a denial. You may exclude terminations due solely to noncompliance with continuing education requirements or failure to pay a renewal fee. If you answer yes, you must attach to this application: a. a written statement with original signature identifying the type of license and explaining the circumstances of incident; and b. a certified copy of the tice of Hearing or other document that states the charges and allegations; and, c. a certified copy of the official document which demonstrates the resolution of the charges or any final judgment. 23. Has any demand been made or judgment rendered against the business entity or any of its partners, members, controlling persons, officers, directors, managers or any shareholders owning 10% or more interest in the business entity for overdue monies by an insurer, insured or producer, or have you ever been subject to a bankruptcy proceeding? If you answer yes, submit a statement summarizing the details of the indebtedness and arrangements for repayment. 24. Has the business entity or any of its partners, members, controlling persons, officers, directors, managers or any shareholders owning 10% or more interest in the business entity, 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? If you answer yes, identify the jurisdiction(s): 25. Has the business entity or any of its partners, members, controlling persons, officers, directors, managers or any shareholders owning 10% or more interest in the business entity, been 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? If you answer yes, you must attach to this application: a. a written statement with original signature summarizing the details of each incident; and b. a copy of the Petition, Complaint or other document that commenced the lawsuit or arbitration; and, c. a copy of the official document which demonstrates the resolution of the charges or any final judgment. 26. Has the business entity or any of its partners, members, controlling persons, officers, directors, managers or any shareholders owning 10% or more interest in the business entity, ever had an insurance agency 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 with original signature summarizing the details of each incident and explaining why you feel this incident should not prevent you from receiving an insurance license; and, b. copies of all relevant documents. Page 4 of 6 LIC (Rev 5/2014)

7 Important tice for Limited Liability Companies: Section (c) of the California Insurance Code (CIC) requires each Limited Liability Company, at the time of licensing pursuant to this chapter and, with respect to surplus line brokers, Chapter 6, and at all times during which the company holds an active license, is required to file with the Insurance Commissioner an annual confirmation demonstrating continuing compliance with the financial security requirements of Section CIC. This annual confirmation is typically satisfied by submitting proof of errors and omissions liability insurance coverage. The aggregate dollar amount of errors and omissions coverage can be in the form of cash, bonds, bank certificates of deposit, U.S. Treasury obligations, etc., held to provide security for claims against the Limited Liability Company. (The amount required over the minimum of $500,000 is at least $100,000 multiplied by the number of licensees rendering professional services on behalf of the company; however, the maximum amount is not required to exceed $5,000, ) For the purposes of satisfying this requirement, you are required to provide one of the following: 1. Complete and return the enclosed Certificate of Coverage (Form LIC CC1A) signed by a representative of the insurance company providing the errors and omissions policy (Form LIC CC1A is available from the departmental website at or, 2. If assets other than the errors and omissions liability insurance are being used to satisfy the security requirements, provide verification from the bank or escrow holder listing the type of asset and the current dollar amount. Applicant s Certification: I (we) certify (or declare) under penalty of perjury that: a. the named business entity intends actively and in good faith to carry on an insurance business with the general public; b. the business entity's articles of incorporation or articles of organization or association or partnership agreement, as the case may be, do not forbid it to act in the capacity for which this application is being made; c. the holding of the license hereby applied for is not incompatible with the laws, rules or regulations of any federal, state, county or municipal government for which it performs work (if any) by which it is licensed (if any); d. if the license is granted, only those natural persons so authorized will transact insurance under each license; e. (Surplus Line and Special Lines' applicants only) - we apply for a license pursuant to the provisions of Chapter 6, Part 2, Division 1 of the Insurance Code of the State of California permitting the solicitation, negotiation and subject to the provision of said Chapter, the effecting of insurance to be procured from or placed with insurers not authorized to transact insurance business in this State. Further, I (we) certify (or declare) under penalty of perjury that I (we) have read the foregoing application and know the contents thereof and that each statement therein made is full, true and correct. I (we) understand that pursuant to Sections 1668 (h) and 1738 of the Insurance Code, any false statements may subject my application to denial and may subject my license(s) to suspension or revocation. Further, pursuant to Insurance Code Sections 1703 and 1733, I (we) authorize disclosure to the Insurance Commissioner of all financial institution records of any fiduciary accounts for the duration of this license. IMPORTANT NOTICE Signature(s) Title Title (type name) (type title) and title) If organization is a partnership, each partner must sign this application. Title Title (type name) (type title) and title) Title Title (type name) (type title) and title) Date Executed, at, (month, day, year) (city) (state) If organization is a corporation, an officer having authority to bind the organization must sign. If organization is a limited liability company, an officer, member or manager having authority to bind the organization must sign. If organization is a nonprofit corporation or unincorporated association, all members must sign. All fees are filing fees and are not refundable or transferable, whether or not the application is acted upon or the examination taken. Page 5 of 6 LIC (Rev 5/2014)

8 Instructions for completing Business Entity application Re: "Business Entity type": Corporation- if already incorporated, attach a copy of your Certificate of Good Standing. If corporation has been formed as a result of a merger, submit a copy of your approved merger papers. Re: "Limited Liability Company" - attach a copy of your approved articles of organization. Additional requirements are listed on page 4. This documentation must be submitted with your application. Re: "Business Entity Name": The true business entity name must be entered. Include commas, hyphens, ampersands, etc. This name is subject to disapproval by the Insurance Commissioner. Re: "Fictitious Name": If you intend to transact insurance in a name other than the true business entity name, enter such fictitious name. This name is subject to disapproval by the Insurance Commissioner. Re: "Designated/Responsible Licensed Producer": You must list all licensed producers intending to transact on behalf of the business entity. All unlicensed producers intending to transact on behalf of the business entity must complete form Re: "Controlling Person": Insurance Code Section (b), in part, defines a "controlling person" as a person who possesses the power to direct or cause the direction of the management and policies of the business entity. Re: "Background Information": If the answer is "yes" to any of these questions, you must submit required documentation. Re: "Applicant s Certification": Partnership - each partner of the partnership must sign. Corporation Limited Liability Company or Association - an officer having authority to bind the Corporation or Association must sign. A) Licenses are issued for a two-year term, which begins the date the first license is issued to the business entity and ends the last day of that calendar month two years later. Subsequent licenses are issued for the balance of the established license term. B) Fees: Filing fees are required for each business entity application submitted, except that Surplus Line or Special Lines' fees may vary - see below: Surplus and Special Surplus Lines Filing fees: $1,070 (2 year term), the fee for an individual surplus line broker that has a $50,000 bond on file. Direct questions regarding this filing to the Producer Licensing Bureau in Sacramento, (916) All fees are filing fees and are not refundable, whether or not the application is acted upon or an examination taken. Mail application with fees to: Department of Insurance, P.O. Box 1139, Sacramento, CA tice: Information Collection and Access Section 31(e) of the California Business and Professional Code allows the State Board of Equalization and the Franchise Tax Board to share taxpayer information and requires the licensee to pay his or her state tax obligation. Section 31 also states that the license may be suspended if the state tax obligation is not paid. Section of the California Civil Code requires the following information to be provided when collecting information from individuals to determine compliance with the group and corporate practice provisions of the law, and to establish positive identification, to match the names of the certified list provided by the Department of Child Support Services to applicants and licensees, and of responding to requests for this information made by child support agencies. Agency: Department of Insurance, Address: 320 Capitol Mall, Sacramento, Ca , Telephone: (800) Title of official responsible for information maintenance: Chief, Producer Licensing Bureau Authority which authorizes the maintenance of the information: California Insurance Code, Chapters 5, 6, 7, 8-Part 2, Division 1 The consequences, if any, of not providing all or part of the requested information: It is mandatory that you provide all information requested. Omission of any item of requested information will result in the application being rejected as incomplete. The principal purposes for which the information is to be used: The information requested will be used to determine qualifications for licensure or certification, to determine compliance with the group and corporate practice provisions of the law and to establish positive identification. Each individual has the right to review files maintained on them by the agency, unless the information is classified as confidential under section (a) of the California Civil Code. Page 6 of 6 LIC (Rev 5/2014)

9 Nation Safe Drivers Services 800 Yamato Road, Suite 100, Boca Raton, FL Tel: Fax: Firm/Agency Questionnaire 1. Business Name and Address: (Business Name) (Street) (City) (State) ( Zip) 2. Business Entity Motor Club License Number: 3. FEIN: - 4. Date of Incorporation/Formation: Business Telephone: ( ) - Business Fax Number: ( ) Designated Representative/Producer Name: 8. Designated Representative/Producer License Number (if applicable): 9. Identify all owners with 10% interest or voting interest, partners, officers and directors of the business entity, or members or managers of a limited liability company: Owner: / Name Title SSN/FEIN Owner: / Name Title SSN/FEIN Owner: / Name Title SSN/FEIN I hereby verify my foregoing statements and answers and declare under penalties of perjury that they are correct. This day of, 20 X

10 State of California Individual Application For Insurance License LIC (Rev 4/2014) Department of Insurance 1. Application Type: Permanent Certificate of Convenience For Department Use Only 2. License Type: Accident and Health Agent (AH) Life-Only Agent (LO) Variable Contract Authority (VC) Property Broker-Agent (PR) Casualty Broker-Agent (CA) Personal Lines Broker-Agent (PL) Limited Lines Auto Insurance Agent (AU) Credit Insurance Agent (CI) Part Time Fraternal Agent (PF) Portable Electronics Insurance Agent (PE) Rental Car Agent (RC) Surplus Line Broker (SL)* Special Lines Surplus Line Broker (SP)* Self-Service Storage Agent (SS) License # Life & Disability Analyst (LA) Motor Club Agent (MC) Cargo Shipper s Agent (CS) Vehicle Service Contract Provider (VS) 3. Last Name First Name Middle Name Suffix 4. Male Female 5. Birthdate (MM/DD/YYYY) 6. Social Security Number (SSN)** 7. Resident Address (P.O. Box not acceptable) 8. City 9. State 10. Zip Code 11. Home Phone Number 12. Are you a citizen of the United States? 13. Are you affiliated with a ( ) (If no, you must supply a clear copy of both sides of your financial institution/bank? work authorization) 14. Business Address (P.O. Box not acceptable.) 15. City 16. State 17. Zip Code 18. Business Phone Number ( ) 19. Business Fax Number ( ) 20. Address (required) 21. Business Web Site Address 22. Mailing Address (P.O. Box is acceptable.) 23. City 24. State 25. Zip Code 26. Special Accommodation Request for Examination If required, arrangements were made prior to taking and passing the license examination. 27. Examination Information: Examination Information: If required, you must first pass your license examination before submitting the license application. After you pass your license examination, please ensure that all required documents are submitted. If you are required to submit documents, please them to: licdocuments@insurance.ca.gov or mail them to CA Dept. of Insurance, Attention: FLASH OLA, 320 Capitol Mall, Sacramento CA *Form LIC 050 must be completed and submitted with Surplus and/or the Special Lines Surplus Broker Application. **Disclosure of your U. S. social security number is mandatory pursuant to Cal. Civil Code, ; Cal. Family Code, 17520(d); and Federal Privacy Act of 1974, 7(a) (2) (B) and 7(b). The social security number will be used primarily for purposes of processing your application, including conducting any necessary investigation into your background. If you fail to disclose your social security number, your application will not be reviewed. An individual has a right of access to certain records containing personal information pertaining to that individual. Individuals may obtain information regarding the location of their records by contacting the Bureau Chief, Producer Licensing Bureau, California Department of Insurance by phone ( ) or by mail, to the following address: 320 Capitol Mall, Sacramento CA

11 28. Work/Personal History: Account for all time for the past five years. Give all employment experiences starting with your current employer working back five years. Include full and part-time work, self-employment, military service, unemployment, and full-time education. Attach separate sheet, if needed. Name City Name City Name City Name City State State State State From Month Year To Month Year Position Held 29. Do you now hold an insurance license and are you adding a line of authority? Or have you ever held an insurance license as a resident in this state or any other state? If yes, complete the following (attach a separate sheet if needed): Type of License State or Province Date License Held Is License in Force? 30. AKA/Alias Are you now using or have you ever used any name other than shown? If yes, list names, dates and reason(s) used: Last First Middle Suffix Dates Used Reason Used Last First Middle Suffix Dates Used Reason Used 31. Fictitious Names: Do you intend to use a fictitious (DBA) name? If yes, list the name: (This name must be approved by the Department prior to use) 32. Life-Only Agent/Part Time Fraternal License Applicants Only: Are you intending to act as a Variable Contract Agent? Are you registered with SECO or FINRA? Central Registration Depository Number (CRD) If CRD# is not provided, acceptable proof of registration must be attached before the authority may be granted. If acceptable proof is not submitted, license will be issued without Variable Contract authority. 33. Life-Only Agent License Applicants Only: Do you intend to limit your activity to the sale of funeral and burial expense policies in accordance with Section of the California Insurance Code? 34. Prelicensing Certificates: Do you certify that you have completed your prelicensing education? If no, your prelicensing education must be completed prior to taking your examination. If yes, you must provide the completion date: Page 2 of 6 LIC (Rev. 4/2014)

12 35. Background Information If you fail to fully disclose any information that is requested or if you make a false statement, your application may be denied. 1. Have you ever been convicted of a felony? For the purpose of this application, you have been convicted if you were ever found guilty by verdict of a judge or jury; and/or ever entered a plea of guilty, nolo contendere or no contest. You must disclose all convictions, even if the cha rges were later di smissed or expunged, your guilty plea was with drawn pursuant to Penal Code Section , or you were placed on probation, received a suspended sentence or just ordered to pay a fine. If you fail to disclo se all convictions, your application may be d enied. You may exclude juvenile offenses tried in juvenile court. If you answer to this background question, you must attach to this application: a) a written statement, with original signature, explaining the circumstances of each conviction or charge; and, b) certified copies of the charging documents, and of the court documents which detail the conviction, resolution of the charges, probation and any final judgment. Federal law (18 U.S.C. 1033) prohibits anyone who has been convicted of a felony involving dishonesty or a breach of trust or who has been convicted of any violation of 18 U.S.C and 1034 from conducting the business of insurance unless they have obtained the written consent of the Insurance Commissioner. It is a violation of this statute to co nduct business of in surance without the Commissioner s written consent. If you have been convicted of a felony involving dishonesty or a breach of trust or a violation of 18 U.S.C and 1034, then you m ust attach a copy of this consent. If you have n ot obtained this written consent you must do so prior to filing your application. 2a. Have you ever been convicted of a felony involving dishonesty or a breach of trust? 2b. If, have you received consent from the California Insurance Commissioner? For the purpose of this application, you have been convicted if you were ever found guilty by verdict of a judge or jury; and/or ever entered a plea of guilty, nolo contendere or no contest. You must disclose all convictions, even if the charges were later dismissed or expunged, your guilty plea was withdrawn pursuant to Penal Code Section , or you were placed on probation, received a suspended sentence or just ordered to pay a fine. If you fail to disclose all convictions, your application may be denied. You may exclude juvenile offenses tried in juvenile court. If you answered to background question 2a, you must attach to this application: a) a written statement, with original signature, explaining the circumstances of each conviction or charge; and, b) certified copies of the charging documents, and of the court documents which detail the conviction, resolution of the charges, probation and any final judgment. 3. Have you ever been convicted of a misdemeanor? For the purpose of this application, you have been convicted if you were ever found guilty by verdict of a judge or jury; and/or ever entered a plea of guilty, nolo contendere or no contest. You must disclose all convictions, even if the cha rges were later di smissed or expunged, your guilty plea was with drawn pursuant to Penal Code Section , or you were placed on probation, received a suspended sentence or just ordered to pay a fine. If you fail to disclose all convictions, your application may be d enied. You may exclude juvenile offenses tried in juvenile court. If you answer to this background question, you must attach to this application: a) a written statement, with original signature, explaining the circumstances of each conviction or charge; and, b) certified copies of the charging documents, and of the court documents which detail the conviction, resolution of the charges, probation and any final judgment. Page 3 of 6 LIC (Rev. 3/2014)

13 35. Background Information continued. If you fail to fully disclose any information that is requested or if you make a false statement, your application may be denied. 4. Have you ever been convicted of a military offense? For the purpose of this application, you have been convicted if you were ever found guilty by verdict of a judge or jury; and/or ever entered a plea of guilty, nolo contendere or no contest. You must disclose all convictions, even if the charges were later dismissed or expunged, your guilty plea was withdrawn pursuant to Penal Code Section , or you were placed on probation, received a suspended sentence or just ordered to pay a fine. If you fail to disclose all convictions, your application may be denied. You may exclude juvenile offenses tried in juvenile court. If you answer to this background question, you must attach to this application: a) a written statement, with original signature, explaining the circumstances of each conviction or charge; and, b) certified copies of the charging documents, and of the court documents which detail the conviction, resolution of the charges, probation and any final judgment. 5. Are you currently charged with committing a crime? Crime includes a felony, a misdemeanor or a military offense. You may exclude traffic citations but should include driving offenses such as, but not limited to, reck less driving, driving under the influence and driving with a suspended license. If you answer to this background question, you must attach to this application: a) a written statement, with original signature, explaining the circumstances of each charge; and, b) certified copies of the charging documents. 6. Have you ever been involved in an administrative proceeding (including matters with the Department of Insurance) regarding any professional or occupational license? For the purpose of this application, Involved means having a license censured, suspended, revoked, cancelled, terminated; or being assessed a fine, placed on probation or surrendering a license to resolve an administrative action. Involved also means being named a party to an administrative or arbitration proceeding which is related to a professional or occupational license. Involved also means having a license application denied or the act of withdrawing an application to avoid denial. You may exclude terminations due solely to noncompliance with continuing education requirements or failure to pay a renewal fee. If you answer to this background question, you must attach to this application: a) a written statement, with original signature, explaining the circumstances of each disciplinary incident; and, b) certified copies of the tice of Hearing or other document that states the charges and allegations; and, of the document which demonstrates the resolution of the charges or any final judgment. 7. Has any business in which you are or were an owner, partner, officer or director ever been involved in an administrative proceeding (including matters with the Department of Insurance) regarding any professional or occupational license? For the purpose of this application, Involved means having a license censured, suspended, revoked, cancelled, terminated; or being assessed a fine, placed on probation or surrendering a license to resolve an administrative action. Involved also means being named a party to an administrative or arbitration proceeding which is related to a professional or occupational license. Involved also means having a license application denied or the act of withdrawing an application to avoid denial. You may exclude terminations due solely to noncompliance with continuing education requirements or failure to pay a renewal fee. If you answer to this background question, you must attach to this application: a) a written statement, with original signature, explaining the circumstances of each disciplinary incident; and, b) certified copies of the tice of Hearing or other document that states the charges and allegations, and of the document which demonstrates the resolution of the charges or any final judgment. 8. Has any demand been made or judgment rendered against you for any overdue monies by any insurer, insured or producer, or have you ever been subject to a bankruptcy proceeding? (Only include bankruptcies that involve funds held on behalf of others). If you answer, submit a statement, with an original signature, summarizing the details of the indebtedness and arrangements for repayment, and/or type and location of bankruptcy. Page 4 of 6 LIC (Rev. 3/2014)

14 35. Background Information continued. If you fail to fully disclose any information that is requested or if you make a false statement, your application may be denied. 9. Have you ever been notified by any jurisdiction of any delinquent tax obligation that is not the subject of a repayment agreement? If you answer, identify the jurisdiction(s): 10. Are you currently a party to or have you 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? If you answer, you must attach to this application: a) a written statement, with original signature, summarizing the details of each incident; b) copy of the Petition, Complaint, or other document that commenced the lawsuit or arbitration; and c) a copy of the official document which demonstrates the resolution of the charges or any final judgment. 11. Have you or any business in which you are or were an 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? If you answer, you must attach to this application: a) a written statement, with original signature, summarizing the details of each incident and explaining why you feel this incident should not prevent you from receiving an insurance license; and, b) copies of any relevant documents. 36. Applicant s Certification: I certify under penalty of perjury that I have read the foregoing application and know the contents thereof and that each statement therein made is full, true and correct. I understand that pursuant to sections 1668(h) and 1738 of the insurance code, any false statement may subject my application to denial and may subject my license(s) to suspension or revocation. Further, pursuant to insurance code sections 1703 and 1733, I authorize disclosure to the insurance commissioner of all financial institution records of any fiduciary accounts for the duration of this license. All fees are filing fees and are not refundable, whether the application is acted upon or an examination taken. Applicant s Signature : City Date tice: Information collection and Access Section 31(e) of the California Business and Professional Code allows the State Board of Equalization and the Franchise Tax Board to share taxpayer information and requires the licensee to pay his or her state tax obligation. Section 31 also states that the license may be suspended if the state tax obligation is not paid. Section of the California Civil Code requires the following information to be provided when collecting information from individuals to determine compliance with the group and corporate practice provisions of the law, and to establish positive identification, to match the names of the certified list provided by the Department of Child Support Services to applicants and licensees, and of responding to requests for this information made by child support agencies. Agency: Department of Insurance, Address: 320 Capitol Mall, Sacramento, CA , Telephone number: (800) Title of official responsible for information maintenance: Chief, Producer Licensing Bureau. Authority which authorizes the maintenance of the information: California Insurance Code, Chapters 5, 6, 7, 8-Part 2, Division 1. The consequences, if any, of not providing all of part of the requested information: It is mandatory that you provide all information requested. Omission of any item of requested information will result in the application being rejected as incomplete. The principal purpose(s) for which the information is to be used: The information requested will be used to determine qualifications for licensure or certification, to determine compliance with the group and corporate practice provisions of the law and to establish positive identification. Each individual has the right to review files maintained on them by the agency, unless the information is classified as confidential under section of the Civil code. Page 5 of 6 LIC (Rev. 3/2014)

15 Instructions for completing application RE: "Applicant name" Enter full legal name. If no middle name, enter (NMN). If any part of your legal name is an initial only, place parentheses around such initial. RE: "Address information" Do not enter the word "same" in any address area. Enter the appropriate address. P0 Box is not acceptable for a resident or business address. Business and mailing addresses are public record and are available to the public. It is the applicant s/licensee s responsibility to immediately notify the department of any change in address. RE: Additional "Exam information". If you fail to appear for a scheduled examination, an additional examination fee will be required for rescheduling. RE: "AKA/Alias" List previously and currently used aliases and maiden names, if any. If you are currently using an "also known as" (AKA) name, which you desire to be noted on record, so state. Abbreviations of true name or "nick" names are not acceptable. RE: "Background questions" If you answer yes to any of these questions, you must submit a signed statement, with your original signature summarizing the details of each event. You must also provide the additional certified documentation described with each question. Prelicensing Education requirements: As of January 1, 2011 all new resident applicants must: A. take an approved minimum 20-hour class for the property broker-agent license exam, and/or; B. take an approved minimum 20-hour class for the casualty broker-agent license exam, and/or; C. take an approved minimum 40 hour class for property broker-agent and casualty broker-agent license examination, and/or; D. take an approved minimum 20-hour class for the life-only agent license exam and/or; E. take an approved minimum 20 hour class for accident and health agent license exam, and/or; F. take an approved minimum 40 hour class for life-only and accident and health agent license examination, and/or; G. take an approved minimum 20-hour class for the personal lines broker-agent license exam, and/or; H. take an approved minimum 20 hour class for the limited lines automobile insurance agent license examination, and/or; I. takes an approved minimum 12-hour class on ethics and the California Insurance Code. An applicant will be taking 32 hours (20 and 12), 52 hours (40 and 12 or 20, 20 and 12), and 72 hours (20, 40 and 12 or 20, 20, 20 and 12) of pre-licensing class hours depending on which combination of licenses are being sought. The following documents are required to be submitted with the application for the specific license types as listed: SL - $50,000 bond form LIC with a properly executed Power of Attorney form attached or a Business Entity Endorsement form LIC 411-8A completed by sponsoring Business Entity and Form LIC 050 must be completed and submitted with Surplus and/or the Special Lines Surplus Broker Application. SP - $10,000 bond form LIC with a properly executed Power of Attorney form attached or a Business Entity Endorsement form LIC 411-8A completed by sponsoring Business Entity and Form LIC 050 must be completed and submitted with Surplus and/or the Special Lines Surplus Broker Application. CS - $10,000 bond form LIC with a properly executed Power of Attorney form attached. CI - Action tice of Appointment form LIC A from the sponsoring insurance company and/or Business Entity Endorsement form LIC 411-8A completed by sponsoring Business Entity. MC - Action tice of Appointment form LIC A from the sponsoring insurance company Forms are available on our Website at To obtain insurance licensing forms by mail, send request to: Department of Insurance, 320 Capitol Mall, Sacramento, CA , or you may phone Sacramento toll free at (800) Mail application with attachments and fees to Department of Insurance, PO Box 1139, Sacramento, CA Page 6 of 6 LIC (Rev. 3/2014)

16 Nation Safe Drivers Services 800 Yamato Road, Suite 100, Boca Raton, FL Tel: Fax: Representative/Producer Questionnaire 1. Full name of applicant: (First Name) (Middle) (Last) 2. Resident Address: (Street) (City) (State) (Zip) 3. Home Telephone Number: ( ) - 4. Social Security Number: Date of Birth: 6. Property & Casualty License Number (if applicable): 7. Business Name and Address: (Business Name) (Street) (City) (State) ( Zip) 8. FEIN: - 9. Business Telephone Number: ( ) Business Fax Number: ( ) I hereby verify my foregoing statements and answers and declare under penalties of perjury that they are correct. This day of, 20 X

17 State of California Business Entity Endorsement LIC 411-8A (Rev 3/1/2015) Producer Licensing Bureau P.O. Box 1139 Sacramento, CA (800) Business Entity Name: Mailing Address: Pursuant to Section 1627 and 1661 of the Insurance Code Department of Insurance License Number To the Insurance Commissioner of the State of California: Effective from the date of filing this notice, the Business Entity hereby endorses the person(s) named to exercise the agency or brokerage powers of the business entity. te: Enter only one endorsement type per line. (Exception SL/SP) *AH - Accident and Health Agent *LO - Life-Only Agent *VC - Variable Contract Authority LI - Life-Limited to the Payment of Funeral & Burial Expenses *PR - Property Broker Agent *CA - Casualty Broker-Agent AU - Limited Lines Automobile Insurance Agent LA - Life and Disability Analyst CS - Cargo Shipper s Agent **CI - Credit Insurance Agent PL - Personal Lines Broker Agent MC - Motor Club Agent SL - Surplus Line Broker SP - Special Lines Surplus Line Broker SL/SP - Surplus Line & Special Lines Surplus Line Broker LS - Life Settlement Broker **Endorsement Type Endorsee s Social Security Number**** Endorsee s Name (as shown on license) Signature and title of authorized representative. Title: Date: Phone Number: ( ) Effective Date of Endorsement Filing fee: Submit $29 filing fee per endorsement type. Enter number of endorsements: X $29 $ Please note, if you are endorsing an applicant for an insurance license, submit only one name per form and attach the form to the application. 1. If you are submitting only an endorsement: Mail Endorsement form and fee to California Department of Insurance, P.O. Box 957, Sacramento, CA or 2. If endorsement is being submitted with original application Mail Endorsement form with application and fee to California Department of Insurance, P.O. Box 1139, Sacramento, CA *If endorsing Life-Only Agent and/or Accident and Health and/or Variable submit only one filing fee or if endorsing Property Broker-Agent and Casualty Broker-Agent, submit only one filing fee ** For Credit Insurance applicants only: submit $41 per endorsement. *** There is no fee for the Life Settlement Broker. **** Disclosure of your U. S. social security number is mandatory pursuant to Cal. Civil Code, ; Cal. Family Code, 17520(d); and Federal Privacy Act of 1974, 7(a) (2) (B) and 7(b). Your social security number will be used primarily for purposes of processing your application, including conducting any necessary investigation into your background. If you fail to disclose your social security number, your application will not be reviewed. An individual has a right of access to certain records containing personal information pertaining to that individual. Individuals may obtain information regarding the location of their records by contacting the Bureau Chief, Producer Licensing Bureau, California Department of Insurance by phone ( ) or by mail, to the following address: 320 Capitol Mall, Sacramento CA

18 State of California Action tice of Appointment LIC A (Rev 3/1/2015) Department of Insurance Insurer Name: Pursuant to Sections 1704 through 1707 and/or 1756 of the Insurance Code FEIN: NAIC # Federal Employer Identification Number To the Insurance Commissioner of the State of California: tice is hereby given that effective from the date shown on this notice; the designated insurer hereby appoints the person(s) named herein to act as its agent. *Appoint Type: Only one appointment type per line. *AH - Accident and Health Agent; *LO - Life-Only Agent; LI - Life-Limited to the Payment of Funeral & Burial Expenses; *PR - Property Broker-Agent; *CA - Casualty Broker-Agent; AU - Limited Lines Auto Insurance Agent; LA - Life and Disability Analyst; CS - Cargo Shipper s Agent; **CI - Credit Insurance Agent; PL - Personal Lines Broker Agent; MC - Motor Club Agent; PF - Part Time Fraternal Agent; TA Limited Lines Travel Agent; DO - Disability Only; HP - Home Protection; VC Variable Contract Appoint Type ** National Producer Number (NPN) CA License # Name: As shown on license Effective date of Appointment Signature of Insurer: Signature must be that of an officer of the Company or a person authorized under a Special Power of Attorney on file with the Department. Name Official Title Date Phone Number ( ) Filing fee: Submit $29 filing fee per appointment type. Enter number of appointments: X $29 $ Please note: if you are appointing an applicant for an insurance license, submit only one name per form and attach the form to the application. If you are submitting only an action notice Mail Action tice and fee to: California Department of Insurance, P.O. Box 928, Sacramento, CA or * If Action tice is being submitted with original application Mail Action tice with Application and fee to: California Department of Insurance, P.O. Box 1139, Sacramento, CA *If endorsing Accident and Health Agent, Life-Only Agent and Variable Contract Authority or Property Broker Agent and Casualty Broker-Agent submit only one filing fee. ** For Credit Insurance applicants only: submit $41 per endorsement.

19 State of California Live Scan Service Request (Applicant) LIC A (Rev. 04/2013) Department of Insurance Attention: Live Scan Service Providers, Resident and nresident License Applicants, and 1033 Consent Waiver (18 U.S.C. 1033) Applicants The California Department of Justice (DOJ) and Federal Bureau of Investigation s (FBI) processing fees are to be paid by the license applicant. Be prepared to pay the fees at the time your fingerprints are taken at the license scan service provider site. The applicant is to make two copies of this form and distribute as follows: 1) First Copy (Original) to the Live Scan Provider; 2) Second Copy to the Applicant. If the applicant completes a 1033 Consent Waiver (18 U.S.C. 1033), that applicant is to make a Third Copy of this form and send it to the California Department of Insurance. Part 1 Applicant s Personal Information Please type or print clearly the information below Applicant Name (Last, First, and Middle) Former Name/AKA s (Last, First) Date of Birth (MM/DD/YYYY) Gender Male Female Height Weight Eye Color Hair Color Place of Birth Social Security Number Driver s License Number Daytime Telephone Number ( ) Residence Address (Street/PO Box, City, State, Zip Code) Department and Live Scan Vendor ONLY Part 2 To be completed by Contributing Agency Agency ORI Number Agency Address OCA Number: A0042 Application Type: (e.g. type of search) License Certificate or Permit California Department of Insurance 320 Capitol Mall, Sacramento, CA Job Title: Insurance 1000 Mail Code: (five-digit code assigned by DOJ) Level of Service: California Department of Justice and Federal Bureau of Investigation Part 3 To be completed by Live Scan Transaction Live Scan Transaction Completed by: (Name of operator) Date Completed Transmitting Agency Terminal ID Amount Collected (For rolling fee) Amount Collected: (For DOJ/FBI Processing) ATI Number Part 4 To be completed by Live Scan for Fingerprint Resubmission Original ATI Number Level of Service Requested for Resubmission California Department of Justice Original - Live Scan operator, Second Copy - Requesting Agency, Third copy Applicant Federal Bureau of Investigation

20 LIC A (Rev. 04/2013) Page 2 Resident Producer Licensing Applicant Instructions Step 1: Completion of Live Scan Form: The following information must be entered in Part 1 of the form by the applicant: Your printed name and former names (if any); Date of birth, gender, height, weight, eye color, hair color, place of birth, social security number (SSN), driver s license number, and residence address. The contributing agency will complete Part 2. The live scan vendor will complete Part 3 and, if necessary, Part 4 of this form. Step 2: Producer Fingerprint Requirement: One set of classifiable electronic fingerprints is required for every California Department of Insurance (CDI) applicant unless the applicant is currently licensed or held a CDI license which expired during the last 12 months. Step 3: Fingerprint Services: Live Scan Fingerprint Services available in California: The California Department of Justice (DOJ) maintains a listing of Live Scan fingerprinting services available to the public. The DOJ list is broken down by county. Fees vary from location to location. Applicants are encouraged to contact the Live Scan provider in advance to verify their current operating hours, fees, etc. This list is available at the following website: For your convenience, CDI's contracted vendor, Accurate Biometrics will have staff available at the CDI s examination sites to complete the fingerprint impression requirement. Step 4: Fees: At CDI s examination site, the total processing fee for the fingerprint impressions taken by CDI s contracted vendor is $58.30 which includes the FBI processing fee of $17, DOJ processing fee of $32, and the CDI s contractor s rolling fee of $9.30. The $58.30 fee is to be paid at CDI s examination site. The applicant may pay with all major credit cards VISA, MasterCard, American Express and Discover Card. In addition, a money order, cashier s check, company check or personal check in the amount of $58.30 made payable to "Accurate Biometrics will also be accepted At PSI s test center, the total processing fee for the fingerprint impressions taken by L-1 Solutions is $68.95 which includes the FBI processing fee of $17, DOJ processing fee of $32, and the rolling fee charged by PSI of $ The $68.95 fee is to be paid at the PSI test center. They accept money order, cashier s check, company check (made payable to L-1 Solutions), VISA and MasterCard. Personal checks and cash will not be accepted. In addition, applicants using a DOJ authorized vendor on DOJ s HLive Scan Fingerprinting vendorsh list will need to pay a fingerprint fee that covers the FBI processing fee of $17, DOJ processing fee of $32, and an additional "rolling fee" charged by the DOJ authorized vendor. The additional "rolling fee" will vary depending on the vendor and is noted on DOJ's list of vendors. License applicants are encouraged to contact the Live Scan provider in advance to verify their current operating hours, location, fees, and their acceptable method of payment (i.e. credit card, cash, ATM). Step 5: Submission of Fingerprint Form: Please take this form to the live scan provider for processing. n-resident Producer Licensing Applicant Instructions Step 1: Completion of Live Scan Form: The following information must be entered in Part 1 of the form by the applicant: Your printed name and former names (if any); Date of birth, gender, height, weight, eye color, hair color, place of birth, social security number (SSN), driver s license number, and residence address. The contributing agency will complete Part 2 of this form. The electronic fingerprint service provider will complete Part 3 and, if necessary, Part 4 of this form. Step 2: Mail Fingerprint Card, Live Scan Form & Fees Directly to Accurate Biometrics. Keep a copy of the Live Scan form your records. Mail original copy of the completed Live Scan form along with your fingerprint card submission and Accurate Biometrics credit card payment form or check for $58.30 made payable to Accurate Biometrics to the following address: Accurate Biometrics, 455 Capitol Mall, Suite 233, Sacramento, CA Step 3: Fees: The following fees must be paid by the non-resident applicant: Processing Fee: The cost of the Accurate Biometrics live scan service is $ The $58.30 processing fee covers the following services: Federal Bureau of Investigation fingerprint check is $17, State of California Department of Justice fingerprint check is $32 and Accurate Biometrics rolling fee is $9.30. Service Fee: A separate fee will be charged for the service of taking the fingerprint impressions by a fingerprint technician or live scan fingerprints by the live scan provider. That fee may vary depending on the fingerprint vendor or live scan provider you choose Consent Waiver (18 U.S.C. 1033) Applicants Step 1: Completion of Live Scan Form: Follow same instructions as indicated above for resident license applicants. Step 2: Fingerprint Services: Follow same instructions as indicated above for resident license applicants. Step 3: Submission of Fingerprint: Follow same instructions as indicated above resident license applicants, however, a third copy of the Live Scan Form must be mailed to the California Department of Insurance, Licensing Background Bureau, 320 Capitol Mall, Sacramento, CA The second copy is to be maintained by the applicant for your records. Step 4: Fees: Follow the same instructions as indicated above for resident license applicants.

21 * Denotes Required Fields Credit Card Payment Form Applicant Name * Name (as it appears on credit card) Company Name (if applicable) * Billing Address Billing Address 2 * City * State/Province * Postal (ZIP) Code * Country * Credit Card #: * Expiration Date (MM/YYYY) * CVC Code: * Total Amount To Be Billed To Credit Card: $58.30 * Card Holder Signature