FORM L-169 Insurance License Application for an Individual

Transcription

1 INSTRUCTIONS FOR FORM L-169 Insurance License Applicatin fr an Individual Fr applicatins received by the Department f Insurance n r befre June 30, 2013 DO NOT use Frm L-169 t renew a license. See the PRODUCERS page f the Department f Insurance web site fr instructins n hw t renew a license. T apply fr a license, r t add a line f authrity t yur license, cmplete and submit Frm L-169 with ther required materials. OR apply nline using the Natinal Insurance Prducer Registry ( web site. Yu can use this set f applicatin and instructins until June 30, If submitting an applicatin after June 30, 2013, btain the current applicatin frm the PRODUCERS page f the Department f Insurance web site ( Carefully read instructins. If yur license applicatin des nt cntain all the necessary frms r dcuments, r is therwise nt cmplete, the applicatin will be rejected. QUESTIONS? Befre calling the Department f Insurance, lk fr the answer t yur questin n the PRODUCERS page f the Department f Insurance Internet web site ( Fr questins nt addressed n ur web site, cntact the Insurance Licensing Sectin: Licensing@azinsurance.gv Phne: , r if calling lng-distance within Arizna. Send yur applicatin materials and fees t INSURANCE LICENSING SECTION, 2910 N 44 TH ST # 210, PHOENIX, AZ Frm L-169 Instructins (Eff. June/2012)

2 INSTRUCTIONS FOR FORM L-169 Insurance License Applicatin fr an Individual D NOT use Frm L-169 t renew a license. Use Frm L-191, IPLUS (iplus.azinsurance.gv) r t renew an existing license. 1. Licensing eligibility requirement. All Arizna-resident applicants (prducers, adjusters, bail bnd agents etc) wh d nt already hld an Arizna-resident insurance license r a nn-resident adjuster wh is nt licensed in their resident state must als submit Frm L Carefully read all instructins befre cmpleting yur applicatin. Incmplete applicatins are returned and delay prcessing. 3. Examinatin requirements. Yu may be required t pass a license examinatin befre submitting yur license applicatin. Fr examinatin infrmatin, visit Prmetric s Internet web site at cntact Prmetric by phne at License expiratin: A new license expires n the last day f the licensee s birth mnth between 3 and 4 years frm the date f issuance. Added license authrity expires n the same date as existing authrity. 5. Fees. Fees are NON-REFUNDABLE and are nt prrated [ARS (B)]. Make yur check r mney rder payable t INSURANCE LICENSING SECTION. The fllwing are fees t btain a new Arizna insurance license OR t add authrity t an existing license: LICENSE FEE: $ (meaning $120 in ttal, regardless f the number f nnsurplus lines brker lines f authrity fr which yu are applying). SURPLUS LINES BROKER LICENSE FEE: The license fee fr Surplus Lines Brker r Mexican Insurance Surplus Lines Brker is: $ t add authrity t an existing license that expires in tw years r less; OR $1, t add authrity t an existing license that expires in mre than tw years. LICENSE FEE FOR BOTH, SURPLUS LINES AUTHORITY AND OTHER AUTHORITY: $1, FINGERPRINT PROCESSING FEE $ The fee pays the Department f Public Safety and FBI t prcess yur fingerprints and perfrm a criminal backgrund check. This fee is separate frm the fee yu pay t have yur prints applied t a fingerprint card. 6. Fingerprint requirements. Yu must include a fingerprint card (Frm FD-258) and fingerprint prcessing fee IF; yu are submitting an INITIALArizna-resident insurance prfessinal applicatin yu are applying t be a nn-resident adjuster and yur resident state des nt license individuals as adjusters.. *********FINGERPRINT CLEARANCE CARDS ARE NOT ACCEPTABLE********* Frm L-169 Instructins (Eff. June/2012)

3 7. nresident applicants. Yur hme state license status will be electrnically verified. A nnresident applicant MUST hld an active resident license in the applicant s actual hme state (a US state r territry), except fr an adjuster (see belw). nresident adjuster applicants wh are nt licensed in their resident state must pass the AZ adjuster exam and prvide a fingerprint card and Frm L-152 If yu are a nnresident applying fr limited-line license authrity that is nt shwn in SECTION II f the applicatin, write the line f authrity n the line entitled, "Other limited line." 8. Relcating t Arizna. Yu may submit a Clearance Letter frm yur prir hme state in lieu f passing Arizna s insurance license exam. The Clearance Letter must be received within 90 days after yur license in yur prir hme state is cancelled.. 9. Bail bnd agent. Submit (with the surety s pwer f attrney) and maintain thrughut the term f the license a $10,000 surety bnd using Frm L-195. Include Frm L-BBAA Pursuant t ARS (A)(9), bail bnd agents may nt emply r assist in the emplyment f any persn wh has been cnvicted in any jurisdictin f: 1. ANY felny 2. ANY theft cnvictin (misdemeanr, felny etc) r; 3. ANY crime invlving carrying r the pssessin f a deadly weapn r dangerus instrument. (misdemeanr, felny, etc) 10. Managing general agent. Frm L-107, cmpleted by an authrized fficial f the insurance cmpany with which yu have a cntract. Frm L-106 in the sum dictated n Frm L-107, which must be accmpanied by the surety s pwer f attrney. 11. Risk management cnsultants. Include written authrizatin frm the plitical subdivisin (city/twn/cunty) with which yu are emplyed. 12. Surplus Lines Brker r Mexican Surplus Lines Brker T transact surplus lines insurance fr an insured whse hme state is within this state, each individual and each business entity must pssess a surplus lines brker license issued by the Arizna Department f Insurance. ARS (A). If the individual will nly be selling, sliciting r negtiating alien insurance fr cverage in Mexic (pursuant t ARS ), the individual and business entity may each apply fr a Mexican Insurance Surplus Lines Brker license in lieu f applying fr a full Surplus Lines Brker license. 13. Variable cntracts agents. Arizna residents must include prf f being actively registered thrugh FINRA with a brker/dealer. ARS (A). Fllw the FINRA Brker Search instructins frm Frm L-169 Instructins (Eff. June/2012)

4 14. If yu answered YES t ne r mre f the questins in Sectin V, yu must include a. a SIGNED statement describing in detail all incidents including names f all parties invlved, dates and lcatins, the names and lcalities f any curts and/r administrative agencies invlved, the dispsitin f each matter, whether the cnvictin, plea r finding was fr a felny r pen-ended charge; AND b. Cpies f any and all indictments, cmplaints, plea agreements, rders f cnvictin, ntices f hearing r trial, sentencing rders, suspensin/revcatin rders and any ther infrmatin which relates t each matter. If cpies are nt available, prvide a letter frm the clerk f the pertinent curt r the fficial invlved stating the recrds are nt available and the reasn. 15. Assumed Name (r DBA). While cnducting insurance business, yu must use yur legal name. T use anther name, submit Frm L-193. SEND ALL LICENSING-RELATED MATERIALS AND FEES TO THE FOLLOWING ADDRESS: Insurance Licensing Sectin 2910 rth 44 th Street, Suite 210 Phenix, Arizna NOTE: The Vilent Crime Cntrl and Law Enfrcement Act f 1994 prhibits any persn cnvicted f any criminal felny invlving dishnesty, breach f trust r a vilatin f the Act frm engaging in the business f insurance withut the specific written cnsent f the apprpriate state insurance regulatry fficial. 18 USC A persn wh des nt btain the specific written cnsent may be subject t federal criminal prsecutin. There is n autmatic waiver fr an individual wh may already pssess a license. Further, the Act prhibits any persn r entity frm willfully permitting a prhibited persn, as described abve, frm engaging in the business f insurance and the Act subjects such a persn r entity t criminal sanctins. Access the Sectin 1033 waiver link frm the FIND ADDITIONAL RESOURCES sectin f the Department f Insurance PRODUCERS page fr additinal infrmatin. THE DEPARTMENT OF INSURANCE IS AN EQUAL EMPLOYMENT OPPORTUNITY AGENCY THAT COMPLIES WITH THE AMERICANS WITH DISABILITIES ACT (ADA) OF Persns with disabilities may request reasnable accmmdatin by cntacting the Department f Insurance ADA Crdinatr, at Frm L-169 Instructins (Eff. June/2012)

5 r APPLICATION FOR AN INDIVIDUAL INSURANCE LICENSE (FORM L-169) FOR APPLICATIONS RECEIVED BY THE ARIZONA DEPARTMENT OF INSURANCE ON OR BEFORE 6/30/ CAREFULLY READ THE ENCLOSED INSTRUCTION PAGES. INCOMPLETE APPLICATIONS WILL BE RETURNED. 2. Cmplete ALL PAGES f this frm and fulfill all requirements shwn in the enclsed instructins. Frms are available n the PRODUCERS page f ur Internet web site ( 3. DO NOT use this frm t renew a license. See the PRODUCERS page f ur web site fr instructins n hw t renew a license. 4. Send yur applicatin materials and payment t: INSURANCE LICENSING SECTION, 2910 rth 44 th Street, Suite 210, Phenix, AZ SECTION I: BUSINESS INFORMATION A. (Legal) Last Name (including Jr/Sr/etc if applicable) B. Full First Name C. Full Middle Name D. Physical Street Address f Place f Business (*may nt be a PO r PMB bx, must be the address yu principally cnduct business at) (required) City State Zip Cde E. Name f Business (if applicable, fr mailing purpses)*: *If the business is invlved in the sale, slicitatin r negtiatin f insurance, that business shall be separately licensed. F. Mailing Address (ptinal; P O bx permitted) City State Zip Cde G. Business Phne w/ Area Cde: H. Fax w/ Area Cde (ptinal): I. Address (ptinal): SECTION II: LINES OF LICENSE AUTHORITY Write an X in the bx t the left f the line(s) f authrity fr which yu are applying: Life Insurance Prducer Prperty Prducer Adjuster Prperty & Casualty Managing General Agent Accident and Health r Sickness Prducer Casualty Prducer Bail Bnd Agent Life Managing General Agent Variable Life and Variable Annuity Prducts Prducer CRD # Credit Insurance Prducer Persnal Lines Prducer Surplus Lines Brker Accident and Health r Sickness Managing General Agent Travel Accident Ticket and Baggage Insurance Prducer Mexican Insurance Surplus Lines Brker Risk Management Cnsultant Other limited line (see instructins):. Please apply fr all lines f authrity yu wish t btain. Failure t d s WILL require an additinal fee and applicatin t add them at a later date. SECTION III: PERSONAL INFORMATION A. Gender Male Female B. Date f Birth: MM DD / C. Scial Security Number [required by ARS (P)]: (required) E. Hme Area Cde and Phne Number: (required) / YYYY D. Physical Street Address f Applicant's Hme (required *may nt be a PO r PMB bx) (required) City State Zip Cde SPACE BELOW IS FOR INSURANCE DEPARTMENT USE ONLY exam passed n / / exam passed n / / License #: TF#: 56 Quad Other (120) 58 Quad SLB (1000) 18 Half SLB (500) 66 Fingerprint (22 X ) PDB Checked Active CRD Verified L-152 submitted License Tech Initials Frm L-169 (Eff. June/2012)

6 SECTION IV: INSURANCE LICENSE HISTORY Are yu presently, r have yu ever been, licensed t transact any kind f insurance in this state r elsewhere? If, attach a list f the insurance licenses yu held and, fr each, the license number, the line(s) f insurance n the license, the state r lcality that issued the license, the date the license was issued and the license expiratin date. SECTION V: ADDITIONAL INFORMATION Carefully read and respnd t each f the fllwing questins. Yu shuld prvide a YES answer even if yu believe an incident has been cleared frm yur recrd. Willful misrepresentatin f any fact required t be disclsed in any applicatin r accmpanying statement is a vilatin f law and a grund t deny yur applicatin. NOTE: ADDITIONAL INFORMATION IS REQUIRED if yu respnd YES t any f the fllwing. Please see paragraph 14 in the instructins. Fr the purpses f this applicatin, "judgment" includes, but is nt limited t, having been fund guilty by judge r jury r pled guilty r n cntest t any charge. Yu must answer even if a cnvictin was dismissed, expunged, pardned, appealed, set aside, vacated r reversed, etc, OR even if applicant had civil rights restred, had a plea withdrawn, r was given prbatin, a suspended sentence, a fine, r successfully cmpleted a diversin prgram. A Have yu EVER had any prfessinal, vcatinal, business license r certificatin refused, denied, suspended, revked r restricted, OR been issued a cnsent rder, an administrative actin OR a fine impsed by any public authrity? B. Have yu EVER withdrawn an applicatin fr a license r certificatin t avid its denial, r have yu EVER surrendered a license r certificatin t avid disciplinary actin? C. Have yu EVER been fund guilty f, have yu had a judgment made against yu fr, r have yu admitted t, any f the fllwing: 1. A felny (f any kind)? Obtaining r attempting t btain any type f license thrugh misrepresentatin r fraud? Frging anther's name t any dcument related t an insurance transactin? Withhlding, misapprpriating, cnverting r stealing mney r prperty? Cmmitting an insurance unfair trade practice r fraud? Using fraudulent, cercive r dishnest business practices including frgery with intent t defraud? Cnducting business in an incmpetent, untrustwrthy r financially irrespnsible manner? Transacting, r helping smene else transact, insurance withut the required license authrity? Intentinally misrepresenting the terms f an actual r prpsed insurance cntract r applicatin fr insurance?... D. Is any case currently pending against yu in any jurisdictin accusing yu f any issue listed in Questin C?:... E. If yu are nt applying fr a bail bnd agent license, answer t applicable. Otherwise, if yu are applying fr a bail bnd agent license, have yu EVER been cnvicted in any jurisdictin f any crime (felny, pen-ended r misdemeanr, etc.) that invlved theft OR carrying, illegally using r pssessing a deadly weapn r dangerus instrument?... t applicable SECTION VI: EMPLOYMENT HISTORY List yur emplyment, insurance and nn-insurance, histry (and perids f unemplyment r educatin) fr the past 5 years. If yu need mre space, attach and sign a separate sheet with the infrmatin. Emplyer Name Psitin Held City/State EMPLOYMENT DATES FROM (mm/yy) TO (mm/yy) SECTION VII: AUTHORIZATION AND RELEASE By signing and submitting this applicatin, yu agree t the fllwing. Yu authrize the Arizna Department f Insurance ( DEPARTMENT ) t cnduct a backgrund investigatin t determine yur fitness fr an insurance license. Yu agree t prmptly respnd t questins that may arise frm the investigatin. Yu authrize and request every persn, firm, cmpany, crpratin, gvernmental agency, curt, assciatin r institutin having cntrl f any dcuments, recrds and ther infrmatin abut yu t furnish the DEPARTMENT with any such infrmatin and yu permit the DEPARTMENT, its emplyees, agents r representatives, and yur authrized insurers, t inspect and make cpies f such dcuments, recrds and ther infrmatin. Yu release, discharge and exnerate the DEPARTMENT, its emplyees, agents and representatives, the State f Arizna, yur authrized insurers, and any persn furnishing infrmatin pursuant t this Authrizatin and Release frm any and all liability that may arise frm the investigatin made by the DEPARTMENT. Yu attest that yu have read and understand the freging. Yu certify, under penalty f denial, suspensin r revcatin f the license and under any ther penalties that may apply that the answers, statements and infrmatin furnished in cnnectin with this license applicatin are true, crrect and cmplete t the best f yur knwledge and belief. Frm L-169 I (Eff. June/2012)

7 Printed Name f Applicant Full Signature f Applicant Frm L-169 I (Eff. June/2012)