Form AID-LI-ANF "Assumed Business Name Filing Form" - Arkansas

What Is Form AID-LI-ANF?

This is a legal form that was released by the Arkansas Insurance Department - a government authority operating within Arkansas. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on May 1, 2020;
  • The latest edition provided by the Arkansas Insurance Department;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form AID-LI-ANF by clicking the link below or browse more documents and templates provided by the Arkansas Insurance Department.

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Download Form AID-LI-ANF "Assumed Business Name Filing Form" - Arkansas

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FORM AID-LI-ANF (5/20)
ARKANSAS INSURANCE DEPARTMENT
LICENSE DIVISION
1 COMMERCE WAY, SUITE104
LITTLE ROCK, AR 72202
PHONE: 501-371-2750
FAX: 501-683-2604
ASSUMED BUSINESS NAME FILING FORM
INSTRUCTIONS:
Ark
. Code Ann. § 23-64-510 requires an insurance producer doing business under any name other than the
producer’s legal name to notify the Insurance Commissioner prior to using the assumed name. An assumed name is
any name under which you do business, but which name is not licensed by the Arkansas Insurance Department.
Filing of an assumed name does not allow commissions to be paid to that assumed name -- commissions can only be
paid to an individual or business entity that is licensed with the Commissioner.
To file the assumed name you must complete the following form and send it to the address listed above. If you are
using multiple assumed names, a form must be completed for each assumed name. There is no fee to file an
assumed name. This form must be completed in full.
1. Legal Name of Licensee: _____________________________________________________________________
2. License Number: ________________________
3. Social Security or Tax ID Number: ________________________
4. Mailing Address of Licensee
__________________________________________________________________________________________
P.O. Box or Street Number
City
State
Zip
5. Assumed Name Being Used:__________________________________________________________________
6. If assumed name is being used at a location other than the above mailing address, give the address of that
location.
__________________________________________________________________________________________
P.O. Box or Street Number
City
State
Zip
I declare that all information in this statement is true and correct.
__________________________________________
Signature
__________________________________________
Typed or Printed Name
__________________________________________
Date Signed
Department Use Only:
Date Received by Department ________________________ Date Keyed _______________________
FORM AID-LI-ANF (5/20)
ARKANSAS INSURANCE DEPARTMENT
LICENSE DIVISION
1 COMMERCE WAY, SUITE104
LITTLE ROCK, AR 72202
PHONE: 501-371-2750
FAX: 501-683-2604
ASSUMED BUSINESS NAME FILING FORM
INSTRUCTIONS:
Ark
. Code Ann. § 23-64-510 requires an insurance producer doing business under any name other than the
producer’s legal name to notify the Insurance Commissioner prior to using the assumed name. An assumed name is
any name under which you do business, but which name is not licensed by the Arkansas Insurance Department.
Filing of an assumed name does not allow commissions to be paid to that assumed name -- commissions can only be
paid to an individual or business entity that is licensed with the Commissioner.
To file the assumed name you must complete the following form and send it to the address listed above. If you are
using multiple assumed names, a form must be completed for each assumed name. There is no fee to file an
assumed name. This form must be completed in full.
1. Legal Name of Licensee: _____________________________________________________________________
2. License Number: ________________________
3. Social Security or Tax ID Number: ________________________
4. Mailing Address of Licensee
__________________________________________________________________________________________
P.O. Box or Street Number
City
State
Zip
5. Assumed Name Being Used:__________________________________________________________________
6. If assumed name is being used at a location other than the above mailing address, give the address of that
location.
__________________________________________________________________________________________
P.O. Box or Street Number
City
State
Zip
I declare that all information in this statement is true and correct.
__________________________________________
Signature
__________________________________________
Typed or Printed Name
__________________________________________
Date Signed
Department Use Only:
Date Received by Department ________________________ Date Keyed _______________________