Form INS3062 "Self-service Storage Business Entity License Application" - Ohio

What Is Form INS3062?

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

Form Details:

  • Released on February 1, 2021;
  • The latest edition provided by the Ohio Department of Insurance;
  • 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 INS3062 by clicking the link below or browse more documents and templates provided by the Ohio Department of Insurance.

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Download Form INS3062 "Self-service Storage Business Entity License Application" - Ohio

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Self-Service Storage
Business Entity License Application
Judith L. French, Director
Mike DeWine, Governor
Licensing Division, 50 W Town Street, 3rd Floor - Suite 300, Columbus OH 43215
Jon Husted, Lt Governor
614-644-2665 | 614-387-0087 (Fax) | insurance.ohio.gov
Please Print or Type)
Check appropriate box for license requested:
Resident License
Non-Resident License
Identify Home State:
Identify Home State License #:
Demographic Information
Business Entity’s Name
Incorporation/Formation Date (MM/DD/YY)
FEIN
2
3
1
If assigned, National Producer Number (NPN)
State of Domicile
Country of Domicile
Is the business entity affiliated with a financial
4
5
6
7
institution/bank?
Yes
No
8
List any other assumed, fictitious, alias or trade names under which you are doing business or intend to do business.
Entity Home Office Address (Physical Street)
City
State
Zip Code
9
10
11
12
Phone Number (include extension)
Fax Number
Business E-Mail Address
Business Web Site Address
13
14
15
16
Mailing Address
P.O. Box
City
State
Zip Code
20
17
18
19
21
All Locations Entity Engages in Self-Service Storage Transactions - Under Same FEIN
(Use separate sheet if necessary)
Physical Street Address
City
State
Zip Code
Phone Number
22
Physical Street Address
City
State
Zip Code
Phone Number
Designated/Responsible Licensed Producer
Identify at least one Designated/Responsible Licensed Individual or Business Entity Agent who will be responsible for the business entity’s compliance with the
23
insurance laws, rules, and regulations of this state. (Individual agent must hold an active Property and Casualty license. Entity can hold an active Property &
Casualty license or a Self-Service Storage license.)
Name
NPN
Email
Name
NPN
Email
Employee/Officer Information – Required if entity derives less than 50% of revenue from sale of self-service storage insurance
Identify at least one employee or officer of the self-service storage facility who will be responsible for the business entity’s compliance with the insurance laws,
24
rules, and regulations of this state.
Resident
Address
E-Mail
Phone
Name
Resident
Address
E-Mail
Phone
Name
Owners, Partners, Officers and Directors – Required if entity derives 50% or more of revenue from sale of self-service storage insurance
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
25
company. (Use a separate sheet of paper if necessary.)
Ownership
Name
Title
SSN/FEIN
Owner:
Yes
No
Interest:
%
Ownership
Name
Title
SSN/FEIN
Owner:
Yes
No
Interest:
%
INS3062 (Rev. 02/2021)
Page 1 of 3
Self-Service Storage
Business Entity License Application
Judith L. French, Director
Mike DeWine, Governor
Licensing Division, 50 W Town Street, 3rd Floor - Suite 300, Columbus OH 43215
Jon Husted, Lt Governor
614-644-2665 | 614-387-0087 (Fax) | insurance.ohio.gov
Please Print or Type)
Check appropriate box for license requested:
Resident License
Non-Resident License
Identify Home State:
Identify Home State License #:
Demographic Information
Business Entity’s Name
Incorporation/Formation Date (MM/DD/YY)
FEIN
2
3
1
If assigned, National Producer Number (NPN)
State of Domicile
Country of Domicile
Is the business entity affiliated with a financial
4
5
6
7
institution/bank?
Yes
No
8
List any other assumed, fictitious, alias or trade names under which you are doing business or intend to do business.
Entity Home Office Address (Physical Street)
City
State
Zip Code
9
10
11
12
Phone Number (include extension)
Fax Number
Business E-Mail Address
Business Web Site Address
13
14
15
16
Mailing Address
P.O. Box
City
State
Zip Code
20
17
18
19
21
All Locations Entity Engages in Self-Service Storage Transactions - Under Same FEIN
(Use separate sheet if necessary)
Physical Street Address
City
State
Zip Code
Phone Number
22
Physical Street Address
City
State
Zip Code
Phone Number
Designated/Responsible Licensed Producer
Identify at least one Designated/Responsible Licensed Individual or Business Entity Agent who will be responsible for the business entity’s compliance with the
23
insurance laws, rules, and regulations of this state. (Individual agent must hold an active Property and Casualty license. Entity can hold an active Property &
Casualty license or a Self-Service Storage license.)
Name
NPN
Email
Name
NPN
Email
Employee/Officer Information – Required if entity derives less than 50% of revenue from sale of self-service storage insurance
Identify at least one employee or officer of the self-service storage facility who will be responsible for the business entity’s compliance with the insurance laws,
24
rules, and regulations of this state.
Resident
Address
E-Mail
Phone
Name
Resident
Address
E-Mail
Phone
Name
Owners, Partners, Officers and Directors – Required if entity derives 50% or more of revenue from sale of self-service storage insurance
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
25
company. (Use a separate sheet of paper if necessary.)
Ownership
Name
Title
SSN/FEIN
Owner:
Yes
No
Interest:
%
Ownership
Name
Title
SSN/FEIN
Owner:
Yes
No
Interest:
%
INS3062 (Rev. 02/2021)
Page 1 of 3
Ohio Department of Insurance
Self-Service Storage Business Entity License Application
Background Questions
Please read the following very carefully and answer every question. All written statements submitted by the Applicant must include an original signature.
26
1a. Has the business entity or any owner, partner, officer or director of the business entity, or member or manager of a limited liability
Yes
No
company, ever been convicted of a MISDEMEANOR, had a judgment withheld or differed, or is the business entity or any owner,
partner, officer or director of the business entity, or member or manager of a limited liability company currently charged with committing
a MISDEMEANOR?
You may exclude the following misdemeanor convictions or pending misdemeanor charges: traffic citations, driving under the influence
(DUI), driving while intoxicated (DWI), driving without a license, reckless driving, or driving with a suspended or revoked license.
You may also exclude juvenile adjudications (offenses where you were adjudicated delinquent in a juvenile court).
1b. Has the business entity or any owner, partner, officer or director of the business entity, or member or manager of a limited liability
Yes
No
company, ever been convicted of a FELONY, had a judgment withheld or differed, or is the business entity or any owner, partner, officer
or director of the business entity, or member or manager of a limited liability company currently charged with committing a FELONY?
You may also exclude juvenile adjudications (offenses where you were adjudicated delinquent in a juvenile court).
If you have a felony conviction involving dishonesty or breach of trust, have you applied for written consent to engage in the business of
N/A
Yes
No
insurance in your home state as required by 18 USC 1033?
If so, was consent granted? (Attach copy of 1033 consent approved by home state.)
N/A
Yes
No
1c.
Has the business entity or any owner, partner, officer or director of the business entity, or member or manager of a limited liability
Yes
No
company, ever been convicted of a MILITARY OFFENSE, had a judgment withheld or differed, or is the business entity or any owner,
partner, officer or director of the business entity, or member or manager of a limited liability company, currently charged with committing
a MILITARY OFFENSE?
NOTE: For Questions 1a, 1b, and 1c, “Convicted” includes, but is not limited to, having been found guilty by verdict of a judge or jury, having
entered a plea of guilty or nolo contendere, or having been given probation, a suspended sentence or a fine.
If “Yes”, you must attach to this application:
a)
a written statement identifying all parties involved (including their percentage of ownership, if any) and explaining the
circumstances of each incident,
b)
a copy of the charging document, and
c)
a copy of the official document, which demonstrates the resolution of the charges or any final judgment.
2.
Has the business entity or any owner, partner, officer or director, or manager or member of a limited liability company, ever been named or
Yes
No
involved as a party in an administrative proceeding regarding any professional or occupational license or registration?
“Involved” means having a license censured, suspended, revoked, canceled, terminated; or, being assessed a fine, a cease and desist order,
a prohibition order, a compliance order, 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 “Yes”, you must attach to this application:
a)
a written statement identifying the type of license; identifying all parties involved (including their percentage of ownership, if
any) and explaining the circumstances of each incident,
b)
a copy of the Notice of Hearing or other document that states the charges and allegations, and
c)
a copy of the official document which demonstrates the resolution of the charges or any final judgment.
3.
Has any demand been made or judgment rendered against the business entity or any owner, partner, officer or director, or member or
Yes
No
manager of a limited liability company, for overdue monies by an insurer, insured or producer, or have you ever been subject to a
bankruptcy proceeding? Do not include personal bankruptcies, unless they involve funds held on behalf of others.
If “Yes”, submit a statement summarizing the details of the indebtedness and arrangements for repayment.
4.
Has the business entity or any owner, partner, officer or director, or member or manager of a limited liability company, ever been notified
Yes
No
by
any
jurisdiction
to
which
you
are
applying
of
any
delinquent
tax
obligation
that
is
not
the
subject
of a repayment agreement?
If “Yes”, identify the jurisdiction(s):
5.
Is the business entity or any owner, partner, officer or director a party to, or ever been found liable in any lawsuit or arbitration proceeding
Yes
No
involving allegations of fraud, misappropriation or conversion of funds, misrepresentation or breach of fiduciary duty?
If “Yes”, you must attach to this application:
a)
a written statement summarizing the details of each incident,
b)
a copy of the Petition, Complaint or other document that commenced the lawsuit, arbitration, or mediation proceedings, and
c)
a copy of the official document, which demonstrates the resolution of the charges or any final judgment.
Applicant’s Name:
INS3062 (Rev. 02/2021)
Page 2 of 3
Ohio Department of Insurance
Self-Service Storage Business Entity License Application
Background Questions - Continued
6.
Has the business entity or any owner, partner, officer or director, or member or manager of a limited liability company, ever had an
Yes
No
insurance agency contract or any other business relationship with an insurance company terminated for any alleged misconduct?
If ”Yes”, you must attach to this application:
a)
a written statement summarizing the details of each incident and explaining why you feel this incident should not prevent you
from receiving an insurance license, and
b)
copies of all relevant documents.
Applicant’s Certification and Attestation
On behalf of the business entity or limited liability company, the undersigned owner, partner, officer or director of the business entity, or member or
27
manager of a limited liability company, hereby certifies, under penalty of perjury, that:
1.
All of the information submitted in this application and attachments is true and complete and I am aware that submitting false information or omitting pertinent or
material information in connection with this application is grounds for license or registration revocation and may subject me and the business entity or limited
liability company to civil or criminal penalties.
2.
Unless provided otherwise by law or regulation of the jurisdiction, the business entity or limited liability company hereby designate the Commissioner, Director or
Superintendent of Insurance, or other appropriate party in each jurisdiction for which this application is made to be its agent for service of process regarding all
insurance matters in the respective jurisdiction and agree that service upon the Commissioner, Director or Superintendent of Insurance, or other appropriate party of
that jurisdiction is of the same legal force and validity as personal service upon the business entity.
3.
The business entity or limited liability company grants permission to the Commissioner, Director or Superintendent of Insurance, or other appropriate party in each
jurisdiction for which this application is made to verify information with any federal, state or local government agency, current or former employer, or insurance
company.
4.
Every owner, partner, officer or director of the business entity, or member or manager of a limited liability company, either (a) does not have a current child-support
obligation, or (b) has a child-support obligation and is currently in compliance with that obligation.
5.
I authorize the jurisdictions to give any information concerning me, as permitted by law, to any federal, state or municipal agency, or any other organization and I
release the jurisdictions and any person acting on their behalf from any and all liability of whatever nature by reason of furnishing such information.
6.
I acknowledge that I understand and will comply with the insurance laws and regulations of the jurisdictions to which I am applying for licensure/registration.
7.
As a Self-Service Storage Limited Lines applicant, I acknowledge that I understand and will comply with the insurance laws and regulations of this state and will
ensure that all endorsees affiliated with applicant will complete all training requirements, that the applicant will be supervised by qualified supervising entity and
that the supervising entity must maintain a registry of all Self-Service Storage entity locations supervised under their authority and all endorsees at each location.
This registry must be made available to the superintendent upon request.
8.
For Non-Resident License Applications, I certify that I am licensed and in good standing in my home state/resident state for Self-Service Storage. If home state
does not offer a Self-Service Storage license, I understand that an application was submitted to Ohio as a resident applicant.
9.
I hereby certify that upon request, I will furnish the jurisdiction(s) to which I am applying, certified copies of any documents attached to this application or
requested by the jurisdiction(s).
10. I certify that the Designated Responsible Producer(s) named on this application understands that he/she is responsible for the business entity’s compliance with the
insurance laws, rules and regulations of the State.
Must be signed by an officer, director, or partner of the business entity, or member or manager if a limited liability company who has authority to act on
behalf of the business entity:
Signature
Date
Type or Print Name
Social Security Number
Title
Address
City
State
Zip
Application Attachments
The following attachments must accompany the application; otherwise the application may be returned unprocessed or considered deficient.
28
1.
Non-refundable fee (check or money order) made payable to the “State of Ohio Treasurer” in the amount of $10.00;
2.
If necessary, any required supporting details or documents.
INS3062 (Rev. 02/2021)
Page 3 of 3
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