Form AID-LI-MGA40 "Managing General Agent Insurance License Application (Corporation, LLC, LLP , and Partnership)" - Arkansas

What Is Form AID-LI-MGA40?

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-MGA40 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-MGA40 "Managing General Agent Insurance License Application (Corporation, LLC, LLP , and Partnership)" - Arkansas

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FORM AID-LI-MGA40 (5/20)
ARKANSAS INSURANCE DEPARTMENT
LICENSE DIVISION
1 COMMERCE WAY, SUITE 104
LITTLE ROCK, AR 72202
PHONE: 501-371-2750
FAX: 501-683-2604
MANAGING GENERAL AGENT INSURANCE LICENSE APPLICATION
(CORPORATION, LLC, LLP, AND PARTNERSHIP)
Check appropriate line for license requested:
Resident License
Non-resident License
Identify Home State: ______________________ Identify Home State License # ___________________
1. Business Entity Name____________________________________________________________________
2. FEIN _____________________________________
3. State of Domicile ___________________________
4. Business Address: _______________________________________________________________________
Street
City
State
Zip
5. Phone number________________________________
Fax # ____________________________
6. Mailing Address ________________________________________________________________________
P.O. Box or Street
City
State
Zip
7. Contact Person for MGA:
Name_____________________________________________ Phone #_____________________________
8. Owners, Partners, Officers and Directors:
Can attach list to application if additional space is needed:
Name ______________________________________ Title______________________________________
Name ______________________________________ Title______________________________________
Name ______________________________________ Title______________________________________
Name ______________________________________ Title______________________________________
Name ______________________________________ Title______________________________________
9. Name of Insurance Company/Companies, which the MGA will represent:
Attach a completed M-41 for each company listed.
Company NAIC # _________________ Company Name ________________________________________
Company NAIC # _________________ Company Name ________________________________________
Company NAIC # _________________ Company Name ________________________________________
10. List Name of Errors and Omissions Carrier, Policy Number and Effective Date:
Carrier Name: ________________________________ Policy # _________________ Date _____________
11. List name of Company issuing surety bond on the MGA, Policy Number and Effective Date:
Company Name: ______________________________ Bond # __________________ Date ____________
FORM AID-LI-MGA40 (5/20)
ARKANSAS INSURANCE DEPARTMENT
LICENSE DIVISION
1 COMMERCE WAY, SUITE 104
LITTLE ROCK, AR 72202
PHONE: 501-371-2750
FAX: 501-683-2604
MANAGING GENERAL AGENT INSURANCE LICENSE APPLICATION
(CORPORATION, LLC, LLP, AND PARTNERSHIP)
Check appropriate line for license requested:
Resident License
Non-resident License
Identify Home State: ______________________ Identify Home State License # ___________________
1. Business Entity Name____________________________________________________________________
2. FEIN _____________________________________
3. State of Domicile ___________________________
4. Business Address: _______________________________________________________________________
Street
City
State
Zip
5. Phone number________________________________
Fax # ____________________________
6. Mailing Address ________________________________________________________________________
P.O. Box or Street
City
State
Zip
7. Contact Person for MGA:
Name_____________________________________________ Phone #_____________________________
8. Owners, Partners, Officers and Directors:
Can attach list to application if additional space is needed:
Name ______________________________________ Title______________________________________
Name ______________________________________ Title______________________________________
Name ______________________________________ Title______________________________________
Name ______________________________________ Title______________________________________
Name ______________________________________ Title______________________________________
9. Name of Insurance Company/Companies, which the MGA will represent:
Attach a completed M-41 for each company listed.
Company NAIC # _________________ Company Name ________________________________________
Company NAIC # _________________ Company Name ________________________________________
Company NAIC # _________________ Company Name ________________________________________
10. List Name of Errors and Omissions Carrier, Policy Number and Effective Date:
Carrier Name: ________________________________ Policy # _________________ Date _____________
11. List name of Company issuing surety bond on the MGA, Policy Number and Effective Date:
Company Name: ______________________________ Bond # __________________ Date ____________
FORM AID-LI-MGA40 (2/2016) Page 2.
PLEASE READ THE FOLLOWING VERY CAREFULLY AND YOU MUST ANSWER EVERY QUESTION.
IF ANY OF THE QUESTIONS IS ANSWERED YES—YOU MUST ATTACH DOCUMENTATION.
12. Has the business entity or any owner, partner, officer or director ever been convicted of, or is the business
entity or any owner, partner, officer or director currently charged with, committing a crime, whether or not
adjudication was withheld?
Yes
No
13. Has the business entity or any owner, partner, officer or director ever been involved in an administrative
proceeding regarding any professional or occupational license?
Yes
No
14. Has any demand been made or judgment rendered against the business entity or any owner, partner, officer
or director for overdue monies by an insurer, insured, or producer, or has any of these entities been subject
to a bankruptcy proceeding?
Yes
No
15. H the business entity or any owner, partner, officer or director ever been notified by any jurisdiction to
which you are applying of any delinquent tax obligation that is not the subject of a repayment agreement?
Yes
No
16. 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 involving allegations of fraud, misappropriation or conversion of funds,
misrepresentation or breach of fiduciary duty?
Yes
No
17. Has the business entity or any owner, partner, officer, or director ever had an insurance agency contract or
any other business relationship with an insurance company terminated for any alleged misconduct?
Yes
No
APPLICANTS CERTIFICATION AND ATTESTATION
The undersigned owner, partner, officer or director of the business entity hereby certifies, under penalty, that:
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 to civil or criminal penalties.
The business entity grants permission to the Commissioner to verify any information supplied with any federal, state, or local government
agency, current or former employer or insurance company.
Every owner, partner, officer or director of the business entity 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.
I authorized the jurisdictions to give any information they may have concerning me 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.
I acknowledge that I understand and comply with the insurance laws and regulations of the jurisdictions to which I am applying for licensure.
For Non-Resident license Applications, I certify that I am licensed and in good standing in my home state/resident state for the lines of authority
requested from the non-resident state.
Must be signed by an Officer, Director, Principal or Partner of the business entity:
Date ______________________________________
___________________________________
Signature
__________________________________________
Typed or Printed Name
__________________________________________
Title
Note:
The original Surety Bond and a copy of the Errors and Omissions Policy must be attached to this
application.
Note: Must attach proof of filing with the Arkansas Secretary of State showing the business entity has filed
as a foreign Corporation or Limited Liability Company with the State of Arkansas.
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