"Motor Club Representative Registration Form" - Nebraska

Motor Club Representative Registration Form is a legal document that was released by the Nebraska Department of Insurance - a government authority operating within Nebraska.

Form Details:

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

Download a fillable version of the form by clicking the link below or browse more documents and templates provided by the Nebraska Department of Insurance.

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Download "Motor Club Representative Registration Form" - Nebraska

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STATE OF NEBRASKA
For DOI Use Only
DEPARTMENT OF INSURANCE
Identifier # ______________
PO Box 82089
Amount ________________
Lincoln, NE 68501
Dist # _________________
www.doi.nebraska.gov
Check # ________________
MOTOR CLUB REPRESENTATIVE
MOTOR CLUB REPRESENTATIVE
REGISTRATION FORM
REGISTRATION FORM
(Please Print or Type)
1) Social Security Number
2) National Producer Number (NPN)
-
-
3) Last Name
4) First Name
5) Middle Name
6) Date of Birth
/
/
7) Residence/Home Address
8) City
9) State
10) Zip Code
11) Home Phone Number
12) Personal Email Address
13) Are you a citizen of the United States?
Yes
No
If No, Which country are you a citizen? ______________________________________________
(If answering No, and this is for a resident application, you must supply proof of eligibility to work in the U.S.)
14) Business Name
15) Business Address
16) City
17) State
18) Zip Code
19) Bus Phone
20) Bus Email Address
Previous Work History (Last 5 Years)
Employer Name
From
To
Background Questions
1a. Have you ever been convicted of a misdemeanor, had a judgment withheld or deferred, or are you currently charged with
committing a misdemeanor?
YES
NO
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
YES
NO
a felony?
You
may
exclude
juvenile adjudications
(offenses
where you were
adjudicated
delinquent
in
a juvenile
court)
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?
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 answer yes to any of these questions, you must attach to this application:
a) a written statement explaining the circumstances of each incident,
b) a copy of the charging document,
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, regarding any professional or occupational license or registration?
YES
NO
“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
or
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.
NOTE: If you answered yes to question number 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.
Rev. 6/2020
DOI-MC Rep
Page 1 of 2
STATE OF NEBRASKA
For DOI Use Only
DEPARTMENT OF INSURANCE
Identifier # ______________
PO Box 82089
Amount ________________
Lincoln, NE 68501
Dist # _________________
www.doi.nebraska.gov
Check # ________________
MOTOR CLUB REPRESENTATIVE
MOTOR CLUB REPRESENTATIVE
REGISTRATION FORM
REGISTRATION FORM
(Please Print or Type)
1) Social Security Number
2) National Producer Number (NPN)
-
-
3) Last Name
4) First Name
5) Middle Name
6) Date of Birth
/
/
7) Residence/Home Address
8) City
9) State
10) Zip Code
11) Home Phone Number
12) Personal Email Address
13) Are you a citizen of the United States?
Yes
No
If No, Which country are you a citizen? ______________________________________________
(If answering No, and this is for a resident application, you must supply proof of eligibility to work in the U.S.)
14) Business Name
15) Business Address
16) City
17) State
18) Zip Code
19) Bus Phone
20) Bus Email Address
Previous Work History (Last 5 Years)
Employer Name
From
To
Background Questions
1a. Have you ever been convicted of a misdemeanor, had a judgment withheld or deferred, or are you currently charged with
committing a misdemeanor?
YES
NO
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
YES
NO
a felony?
You
may
exclude
juvenile adjudications
(offenses
where you were
adjudicated
delinquent
in
a juvenile
court)
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?
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 answer yes to any of these questions, you must attach to this application:
a) a written statement explaining the circumstances of each incident,
b) a copy of the charging document,
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, regarding any professional or occupational license or registration?
YES
NO
“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
or
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.
NOTE: If you answered yes to question number 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.
Rev. 6/2020
DOI-MC Rep
Page 1 of 2
Applicant’s Name: _______________________________________________
Background Questions (Continued)
3. Has any demand been made or judgment rendered against you or any business in which you are or were an owner, partner,
officer or director, or member or 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
YES
NO
on behalf of others.
If you answer yes, submit a statement summarizing the details of the indebtedness and arrangements for repayment, and/or type and
location of bankruptcy.
4. Have you 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
If you answer yes, identify the jurisdiction(s): _________________________________________________________________
5. Are you currently a party to, or have you ever been found liable in, any lawsuit, arbitrations or mediation proceeding involving
YES
NO
allegations of fraud, misappropriation or conversion of funds, misrepresentation or breach of fiduciary duty?
6. Do you have a child support obligation in arrearage?
YES
NO
Applicant’s Certification and Attestation
The Applicant must read the following very carefully:
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 revocation or denial of
the motor club registration 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. For Non-Resident Applications, I certify that I am licensed or registered and in good standing in my home state/resident state for the lines of authority requested
from the non-resident state.
8. 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).
9. I have received training from the motor club or have otherwise qualified by experience in the business of clubs rendering motor club services.
_________________________________________________________________________
__________________________________________________________
Original Applicant Signature
Month/Day/Year
Additional Requirements
1. Please include proof of completion of an approved Motor Club Training course or indicate that you have
passed Nebraska Motor Club licensing exam.
2. Please also include a registration fee of $5.00 with your application and mail the completed form to:
NEBRASKA DEPARTMENT OF INSURANCE
INSURANCE LICENSING DIVISION
P.O. BOX 82089
LINCOLN, NE 68501-2089
E-mail: DOI.Licensing@Nebraska.gov
Licensing Division: (402) 471-4913
Toll Free: (833) 410-5609
Fax: (402) 471-4610
Rev. 6/2020
DOI-MC Rep
Page 2 of 2
Page of 2