Form INS3271 "Individual Surplus Line Broker License Renewal/Continuation" - Ohio

What Is Form INS3271?

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 INS3271 by clicking the link below or browse more documents and templates provided by the Ohio Department of Insurance.

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Download Form INS3271 "Individual Surplus Line Broker License Renewal/Continuation" - Ohio

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Individual Surplus Line Broker
License Renewal/Continuation
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 | 614-387-0096 (Fax) | insurance.ohio.gov
(Please Print or Type)
Check appropriate box for license requested:
Resident OH License #:
Non-Resident OH License #:
Identify Home State:
Identify Home State License #:
Demographic Information
1
National Producer Number (NPN)
2
Date of Birth
Last Name
JR./SR. etc
First Name
3
4
Residence/Home Address (Physical Street)
City
State
8
Zip or Foreign Country
6
5
7
Individual Applicants Email Address
9
Business Entity’s Name
10
Business Address (Physical Street)
12
P.O. Box
13
City
State
Zip or Foreign Country
11
15
14
Business Phone Number (extension)
Business Fax Number
Business E-Mail Address
Business Web Site Address
18
19
16
17
Mailing Address
P.O. Box
City
State
Zip or Foreign Country
23
20
21
22
24
Agency or Business Entity Affiliations
List your Insurance Agency Affiliations: (Complete only if the applicant is to be licensed as an active member of the business entity)
25
FEIN
NPN
Name of Agency
FEIN
NPN
Name of Agency
Background Questions
The Applicant must read the following very carefully and answer every question. All written statements submitted by the Applicant must include an
26
original signature.
1a. Have you ever been convicted of a MISDEMEANOR, had a judgment withheld or deferred, or are you currently charged with committing
Yes
No
a MISDEMEANOR, which has not been previously reported to this insurance department?
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. Have you ever been convicted of a FELONY, had a judgment withheld or deferred, or are you currently charged with committing a
Yes
No
FELONY, which has not been previously reported to this insurance department?
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
N/A
Yes
No
business of 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
INS3271 (Rev. 02/2021)
Page 1 of 3
Individual Surplus Line Broker
License Renewal/Continuation
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 | 614-387-0096 (Fax) | insurance.ohio.gov
(Please Print or Type)
Check appropriate box for license requested:
Resident OH License #:
Non-Resident OH License #:
Identify Home State:
Identify Home State License #:
Demographic Information
1
National Producer Number (NPN)
2
Date of Birth
Last Name
JR./SR. etc
First Name
3
4
Residence/Home Address (Physical Street)
City
State
8
Zip or Foreign Country
6
5
7
Individual Applicants Email Address
9
Business Entity’s Name
10
Business Address (Physical Street)
12
P.O. Box
13
City
State
Zip or Foreign Country
11
15
14
Business Phone Number (extension)
Business Fax Number
Business E-Mail Address
Business Web Site Address
18
19
16
17
Mailing Address
P.O. Box
City
State
Zip or Foreign Country
23
20
21
22
24
Agency or Business Entity Affiliations
List your Insurance Agency Affiliations: (Complete only if the applicant is to be licensed as an active member of the business entity)
25
FEIN
NPN
Name of Agency
FEIN
NPN
Name of Agency
Background Questions
The Applicant must read the following very carefully and answer every question. All written statements submitted by the Applicant must include an
26
original signature.
1a. Have you ever been convicted of a MISDEMEANOR, had a judgment withheld or deferred, or are you currently charged with committing
Yes
No
a MISDEMEANOR, which has not been previously reported to this insurance department?
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. Have you ever been convicted of a FELONY, had a judgment withheld or deferred, or are you currently charged with committing a
Yes
No
FELONY, which has not been previously reported to this insurance department?
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
N/A
Yes
No
business of 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
INS3271 (Rev. 02/2021)
Page 1 of 3
Ohio Department of Insurance
INDIVIDUAL SURPLUS LINE BROKER LICENSE RENEWAL/CONTINUATION
Background Questions (Continued)
1c. Have you ever been convicted of a MILITARY OFFENSE, had a judgment withheld or deferred, or are you currently charged with
Yes
No
committing a MILITARY OFFENSE, which has not been previously reported to this insurance department?
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 no contest, or having been given probation, a suspended sentence, or a fine.
If you answered “Yes” to any of the above questions (1a, 1b, or 1c), you must attach to this application:
a)
a written statement 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.
Have you ever been named or involved as a party in an administrative proceeding including FINRA sanction or arbitration proceeding
Yes
No
regarding any professional or occupational license or registration, which has not been previously reported to this insurance department?
“Involved” means having a license censured, suspended, revoked, canceled, terminated; or, being assessed a fine, placed on probation,
sanctioned 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, or registration. “Involved” also means
having a license, or registration application denied or the act of withdrawing an application to avoid a denial. INCLUDE any business so
named because of your actions in your capacity as an owner, partner officer, director, or member or manager of a Limited Liability
Company. You may exclude terminations due solely to noncompliance with continuing education requirements or failure to pay a renewal
fee.
If you answered “Yes” to question 2, you must attach to this application:
a)
a written statement identifying the type of license 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.
Do you have a child support obligation in arrearage, which has not been previously reported to this insurance department?
Yes
No
If you answered “Yes” to question 3, answer the following:
a)
by how many months are you in arrearage?
Months
Yes
No
b)
are you currently subject to and in compliance with any repayment agreement?
Yes
No
c)
are you the subject of a child support related subpoena/warrant?
4.
Are you a member or veteran of the armed forces, or the spouse or surviving spouse of a service member or veteran?
Yes
No
Applicant’s Certification and Attestation
The Producer must read the following very carefully:
27
1.
I hereby certify that, under penalty of perjury, all of the information submitted in this application and attachments is true and complete. I am aware that submitting false
information or omitting pertinent or material information in connection with this application is grounds for license revocation or denial of the license and may subject me to
civil or criminal penalties.
2.
Unless provided otherwise by law or regulation of the jurisdiction, I hereby designate the Commissioner, Director or Superintendent of Insurance, or other appropriate party in
each jurisdiction for which this application is made to be my 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
myself.
3.
I further certify that I grant 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.
I further certify that, under penalty of perjury, (a) I have no child-support obligation, (b) I have a child-support obligation and I am currently in compliance with that
obligation, or (c) I have identified my child support obligation arrearage on this application.
5.
I authorize the jurisdictions to which this application is made 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.
7.
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).
Original Producer Signature
Date
Full Legal Name (Printed or Typed)
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 $100.00;
2.
Continuation certificate for $25,000 surplus lines broker bond (resident applicants only);
3.
Completion of the attached Ohio Specific Bond Form (resident applicants only); and
4.
If necessary, any required supporting details or documents.
INS3271 (Rev. 02/2021)
Page 2 of 3
Ohio Department of Insurance
INDIVIDUAL SURPLUS LINE BROKER LICENSE RENEWAL/CONTINUATION
Application Attachments
SURPLUS LINES BROKER BOND
AS PROVIDED BY SECTION 3905.35, REVISED CODE OF OHIO
Bond Number:
Effective Date:
KNOW ALL MEN BY THESE PRESENTS;
We,
as Principal, an applicant for an Ohio
Surplus Lines Broker license, and
as Surety, hereon and admitted
To conduct surety business in Ohio, bind ourselves to the State of Ohio in the sum of twenty-five thousand ($25,000) dollars, for the
payment of such sum, which sum shall be the limit of total aggregate liability hereunder.
The condition of this obligation is such that whereas the said Principal has made application to the Superintendent of
Insurance for a license as a surplus lines broker, in accordance with section 3905.30 of the Revised Code of Ohio, and is required by
section 3905.35 of the Revised Code of Ohio to give bond payable to said state, in the sum of twenty-five thousand ($25,000) dollars,
and conditioned as set forth in section 3905.35 of the Revised Code of Ohio.
If such license is issued to the said Principal, the Principal shall faithfully comply with sections 3905.30 to 3905.36,
inclusive, of the Revised Code of Ohio.
The Surety shall be released from liability for future breaches of the condition of this bond upon giving sixty (60) days
written notice to the Principal and the Superintendent of Insurance of its desire to be released.
In witness whereof, the Principal has subscribed the Principal’s full and correct name on the date and at the place entered
opposite the Principal’s signature, and the Surety has subscribed its full and correct name and affix its corporate seal, if any, on the
date and at the place shown opposite its signature.
Principal
Date
Address
Surety
Date
Address
A COPY OF THE POWER OF ATTORNEY EVIDENCING AUTHORITY OF THE SIGNER OF THE BOND
ON BEHALF OF THE SURETY MUST BE ATTACHED.
INS3271 (Rev. 02/2021)
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