Form DOI-9002A "Designated Responsible Licensed Producer Amendment Form" - Nebraska

What Is Form DOI-9002A?

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

Form Details:

  • Released on June 1, 2020;
  • The latest edition provided by the Nebraska 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 DOI-9002A by clicking the link below or browse more documents and templates provided by the Nebraska Department of Insurance.

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Download Form DOI-9002A "Designated Responsible Licensed Producer Amendment Form" - Nebraska

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STATE OF NEBRASKA
DEPARTMENT OF INSURANCE
LICENSING DIVISION
www.DOI.Nebraska.gov
DESIGNATED RESPONSIBLE LICENSED PRODUCER
AMENDMENT FORM
Business Entity Name
License Number
The designated producer for the agency shall have full responsibility for the conduct of all business transactions of the
insurance agency within the state relative to insurance and shall be an active member of the agency. Any individual
associated with a licensed agency who solicits insurance shall be a licensed producer. No agency shall pay any
commission to anyone other than a licensed producer and no licensed producer shall assign any commissions to any
unlicensed agency.
Adding Designated Producer
**No more than 4 licensed producers may be designated for a specific agency**
Producer’s Name
Producer’s License #
Producer’s Name
Producer’s License #
Removing Designated Producer
Producer’s Name
Producer’s License #
Producer’s Name
Producer’s License #
AUTHORIZATION
A designated producer must sign below and the form must be executed by a notary. (If removing a name, notary information is
not required.) Completed forms can be emailed, mailed, or faxed to the address on the bottom of this form. DRLP information
can be verified with the License Manager Option at www.StateBasedSystems.com.
_____________________________________________
________________________
Signature Designated Producer
Month/Day/Year
_____________________________________________
________________________
Signature Designated Producer
Month/Day/Year
Subscribed to in my presence and duly sworn this __________ day of ____________________, 20______.
State of ___________________________________ County of ____________________________________.
________________________________________
Notary Public
Rev. 6/20
DOI- 9002A
Nebraska Department of Insurance
P.O. Box 82089 • Lincoln, NE 68501 • Fax (402) 471-4610 • Ph (402) 471-4913
Toll Free (833) 410-5609 • doi.licensing@Nebraska.gov
STATE OF NEBRASKA
DEPARTMENT OF INSURANCE
LICENSING DIVISION
www.DOI.Nebraska.gov
DESIGNATED RESPONSIBLE LICENSED PRODUCER
AMENDMENT FORM
Business Entity Name
License Number
The designated producer for the agency shall have full responsibility for the conduct of all business transactions of the
insurance agency within the state relative to insurance and shall be an active member of the agency. Any individual
associated with a licensed agency who solicits insurance shall be a licensed producer. No agency shall pay any
commission to anyone other than a licensed producer and no licensed producer shall assign any commissions to any
unlicensed agency.
Adding Designated Producer
**No more than 4 licensed producers may be designated for a specific agency**
Producer’s Name
Producer’s License #
Producer’s Name
Producer’s License #
Removing Designated Producer
Producer’s Name
Producer’s License #
Producer’s Name
Producer’s License #
AUTHORIZATION
A designated producer must sign below and the form must be executed by a notary. (If removing a name, notary information is
not required.) Completed forms can be emailed, mailed, or faxed to the address on the bottom of this form. DRLP information
can be verified with the License Manager Option at www.StateBasedSystems.com.
_____________________________________________
________________________
Signature Designated Producer
Month/Day/Year
_____________________________________________
________________________
Signature Designated Producer
Month/Day/Year
Subscribed to in my presence and duly sworn this __________ day of ____________________, 20______.
State of ___________________________________ County of ____________________________________.
________________________________________
Notary Public
Rev. 6/20
DOI- 9002A
Nebraska Department of Insurance
P.O. Box 82089 • Lincoln, NE 68501 • Fax (402) 471-4610 • Ph (402) 471-4913
Toll Free (833) 410-5609 • doi.licensing@Nebraska.gov