Form AID-LI-RP MOTOR CLUB "Uniform Application for Arkansas Individual Resident Insurance Producer License" - Arkansas

What Is Form AID-LI-RP MOTOR CLUB?

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 February 1, 2016;
  • 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-RP MOTOR CLUB 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-RP MOTOR CLUB "Uniform Application for Arkansas Individual Resident Insurance Producer License" - Arkansas

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Revised 2/2016
ARKANSAS INSURANCE DEPARTMENT
LICENSE DIVISION
RD
1200 WEST 3
STREET
LITTLE ROCK, AR 72201
PHONE: 501-371-2750; FAX: 501-683-2604
Website:
www.insurance.arkansas.gov/license.htm
Producer License for Motor Club
1.
a.
Resident applicant must complete the Arkansas Individual Resident Insurance Producer License Application form AID-LI-RP
MOTOR CLUB and attach a cashier’s check, company check, or money order in the amount of $20.00 made payable to
“Arkansas Insurance Department Trust Fund.” The fee is for a two year license.
b.
EFFECTIVE MAY 1, 2006: RESIDENTS ONLY: The Arkansas Insurance Department is required to complete criminal
background checks on all resident applicants. The applicant must complete the Arkansas State Police Form ASP-122 (located
at the end of the License Application). You must also attach a separate company, agency, money order or cashier’s check in
the amount of $22.00 made payable to the “Arkansas Insurance Department.” No personal checks accepted.
NON-RESIDENTS: Must hold a resident license of motor club in their home state or another state if the home state
does not license motor club. The nonresident must complete a motor club application with a $25.00 fee. A nonresident
does not complete a criminal background form.
c.
Application forms and fees should be mailed to:
Arkansas Insurance Department
License Division
1200 West Third Street
Little Rock, AR 72201-1904
These fees are fully earned when the application is processed. These fees are not refundable.
2.
3.
If the applicant has held a license in another state, a letter of clearance must be submitted with the application.
4.
The applicant must be at least 18 years of age or if not of legal age, minority rights must be removed by a court order and a copy of
the court order must be forwarded along with the application and fees.
5.
How to complete the License Application:
Since an application is a legal form, certain fields of information are required and must be completed prior to the application being
processed. If the required information is not disclosed on the application, the application will be returned for completion. These
instructions illustrate the specific areas of the application that must have responses before the application can be processed. If the
information is required, the item is marked “a required field,” and you must provide us with this information. If you reach a line
which is not required and the question does not apply to you, then mark the line “N/A.” However, if you have information you can
include it in the non-required filed -- one example is your e-mail address. If the Department has your e-mail address, we can send
e-mail notices of important changes to laws and rules that govern your license. Since this is a legal document, corrections should be
made by drawing one line through the incorrect information, rather than scratching out the information or using liquid paper.
Illegible applications will be returned unprocessed.
Page 1 of Application
1.
Social Security Number---a required field
2.
If assigned, National Producer Number (NPN)
3.
If applicable, NASD Individual Central Registration Depository (CRD) Number
4.
Are you affiliated with a financial institution/bank? ---a required field
5.
Last Name--- a required field
Revised 2/2016
ARKANSAS INSURANCE DEPARTMENT
LICENSE DIVISION
RD
1200 WEST 3
STREET
LITTLE ROCK, AR 72201
PHONE: 501-371-2750; FAX: 501-683-2604
Website:
www.insurance.arkansas.gov/license.htm
Producer License for Motor Club
1.
a.
Resident applicant must complete the Arkansas Individual Resident Insurance Producer License Application form AID-LI-RP
MOTOR CLUB and attach a cashier’s check, company check, or money order in the amount of $20.00 made payable to
“Arkansas Insurance Department Trust Fund.” The fee is for a two year license.
b.
EFFECTIVE MAY 1, 2006: RESIDENTS ONLY: The Arkansas Insurance Department is required to complete criminal
background checks on all resident applicants. The applicant must complete the Arkansas State Police Form ASP-122 (located
at the end of the License Application). You must also attach a separate company, agency, money order or cashier’s check in
the amount of $22.00 made payable to the “Arkansas Insurance Department.” No personal checks accepted.
NON-RESIDENTS: Must hold a resident license of motor club in their home state or another state if the home state
does not license motor club. The nonresident must complete a motor club application with a $25.00 fee. A nonresident
does not complete a criminal background form.
c.
Application forms and fees should be mailed to:
Arkansas Insurance Department
License Division
1200 West Third Street
Little Rock, AR 72201-1904
These fees are fully earned when the application is processed. These fees are not refundable.
2.
3.
If the applicant has held a license in another state, a letter of clearance must be submitted with the application.
4.
The applicant must be at least 18 years of age or if not of legal age, minority rights must be removed by a court order and a copy of
the court order must be forwarded along with the application and fees.
5.
How to complete the License Application:
Since an application is a legal form, certain fields of information are required and must be completed prior to the application being
processed. If the required information is not disclosed on the application, the application will be returned for completion. These
instructions illustrate the specific areas of the application that must have responses before the application can be processed. If the
information is required, the item is marked “a required field,” and you must provide us with this information. If you reach a line
which is not required and the question does not apply to you, then mark the line “N/A.” However, if you have information you can
include it in the non-required filed -- one example is your e-mail address. If the Department has your e-mail address, we can send
e-mail notices of important changes to laws and rules that govern your license. Since this is a legal document, corrections should be
made by drawing one line through the incorrect information, rather than scratching out the information or using liquid paper.
Illegible applications will be returned unprocessed.
Page 1 of Application
1.
Social Security Number---a required field
2.
If assigned, National Producer Number (NPN)
3.
If applicable, NASD Individual Central Registration Depository (CRD) Number
4.
Are you affiliated with a financial institution/bank? ---a required field
5.
Last Name--- a required field
Motor Club Instructions
Page 2
First Name-- a required field –This must be your legal name—no nicknames.
6.
7.
Middle Name---not required
8.
Date of Birth--- a required field
Resident/Home Address-- a required field—must be a physical address cannot be a P.O. Box
9.
10. P.O. Box---not required but you can complete if you want mail sent to that address
11. City--- a required field
12. State-- a required field
13. Zip ---- a required field
14. Foreign Country
15. Home phone number-- a required field---you can use cell phone number if you do not have a home
phone.
16. Gender--- a required field
17. Are you a Citizen of the United States--- a required field—if you are not a citizen you need to attach a copy of your
permit to live and work in the United States.
18. Business name---not a required field, but you can provide the information if you have a business Name.
19. Business Address—not a required field
20. P.O. Box—not a required field
21. City-not a required field
22. State—not a required field
23. Zip—not a required field
24. Foreign Country
25. Business Phone Number—not a required field
26. Business Fax Number—not a required field
27. Business e-mail Address—not a required field (e-mail address information should be given so you can receive information
from the Department.
28. Business Web Site Address—not a required field
29. Applicant’s Mailing Address-- a required field
30. P.O. Box---not required but complete if mail is to be sent to the P.O. Box
31. City-- a required field
32. State-- a required field
Motor Club Instructions
Page 3
33. Zip-- a required field
34. Foreign Country
35. Assumed Business Name/Trade Name--- not a required field but should be given if you will use an assumed business
name.
36. Agency or Business Entity Affiliation— not a required field; however, completing this field will not put you on an agency
license—the agency must submit an addition form #AID-LI-AGY-ADD and fee. This form can be found on the
Department Website
www.insurance.arkansas.gov
under the License Division under License Forms.
37. Employment History-- a required field –you must show a full 5 years of employment history and your dates must be
consistent. If you run out of space you can put information on a piece of paper and attach to the application. Begin with
the present then work backwards. This chronology should also include unemployment, military service or full time
education.
Page 2 of Application
38. Type of License---should be Producer---and Lines of Authority --- a required field
38a. Have you ever or are you currently licensed as agent, producer, consultant or broker in Arkansas ---
a required field.
If yes, list the dates and type of license--- a required field
38b. Have you ever or are currently licensed as agent, producer, etc in another state-- a required field
If you have been licensed in another state in the last 5 years include a clearance letter from the state. A Clearance Letter
indicates that your resident license in the prior state has been cancelled and you were in “good standing” at the time of
cancellation.
39. Required Fields –Required Documentation
If you answer any of the questions yes, you must attach a statement detailing what occurred and what was the
outcome of the occurrence. The application indicates what additional documentation is required with the exception of
35.7 and if you answer yes, attach a statement regarding the reason for the arrearage, and documentation from Child
Support Enforcement showing your current status of arrearage. If you have filed a bankruptcy, then attach a current
and complete credit report to your application.
Page 3 of Application
40.
Required Fields
The application must be dated and signed with your full legal name---no nickname or printed name. It must be a wet
signature—not a stamp.
The next line must contain your full legal name—printed or typed
Any questions regarding the completion of an application should be address to the Arkansas Insurance Department License
Division at 501-371-2750.
Form AID-LI-RP MOTOR CLUB (2/2016)
ARKANSAS INSURANCE DEPARTMENT
LICENSE DIVISION
1200 WEST THIRD STREET, LITTLE ROCK, AR 72201
PHONE: 501-371-2750; FAX: 501-683-2604
Website:
www.insurance.arkansas.gov/License.htm
Uniform Application for Arkansas Individual Resident Insurance Producer License
(Please Print or Type)
1
Soc. Security Number
If assigned, National Producer Number (NPN)
2
If applicable, NASD Individual Central Registration Depository (CRD)
Are you affiliated with a financial institution/bank?
3
4
Number
Yes
No
Last Name
JR./SR. etc.
First Name
Middle Name
Date of Birth
5
8
6
7
Residence/Home Address (Physical Street)
P.O. Box
City
State
Zip Code
Foreign Country
9
11
12
13
10
14
Home Phone Number
Gender
Are you a Citizen of the United States? (Check One)
15
16
17
Male
Female
Yes
No
(If No, of which country are you a citizen?)
(If No, you must supply proof of eligibility to work in the U.S.)
Business Entity Name
18
Business Address (Physical Street)
P.O. Box
City
State
Zip Code
Foreign Country
19
22
20
21
23
24
Business Phone Number
Business Fax Number
Business E-Mail Address
Business Web Site Address
25
26
27
28
Applicant’s Mailing Address
P.O. Box
City
State
Zip Code
Foreign Country
29
30
31
33
32
34
a. List any other assumed, fictitious, alias, maiden or trade names under which you have used in the past to do business, are currently doing business or intend to do
35
business.
b. List any trade names under which you are currently doing business or intend to do business.
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)
36
FEIN ________________________ NPN ___________________ Name of Agency ___________________________________________________________
FEIN ________________________ NPN ___________________ Name of Agency ___________________________________________________________
FEIN ________________________ NPN ___________________ Name of Agency ___________________________________________________________
Employment History
Account for all time for the past five years. Give all employment experience starting with your current employer working back five years. Include full and part-time
37
work, self-employment, military service, unemployment and full-time education.
From
To
Month
Year
Month
Year
Position Held
Name
City
State
Foreign Country
Name
City
State
Foreign Country
Name
City
State
Foreign Country
Name
City
State
Foreign Country
Department Use Only:
Date received _______________________
Funds Received____________________ Ch # RS #_____________________
Date Processed ___________________ Other _____________________________________________________________________________________________
ASI Received Dated _________________________ Date Passed ______________________ Exam Passed ______________ _____________ ______________
Form AID-LI-RP MOTOR CLUB (2/2016)
Page 2
Jurisdiction and Type of License Requested
Next to each jurisdiction, check the license type(s) and line(s) of authority for which you are applying.
38
License Types:
Producer
Limited Lines:
Motor Club
38a. Have you ever or are you currently licensed as an agent, producer, consultant or broker in Arkansas?
Yes
No
If yes, list the dates and the type of license _____________________________________________________________________________________________
38b. Have you ever or are you currently licensed as an agent, producer, Consultant, broker or adjuster in another state?
Yes
No
If yes, list the dates and the type of license ______________________________________________________________________________________________
Background Information
The Applicant must read the following very carefully and answer every question. All copies of documents must be certified. All written
39
statements submitted by the Applicant must include an original signature.
1. Have you ever been convicted of a crime, had a judgment withheld or deferred, or are you currently charged with committing a crime?
Yes
No
Note: “Crime” includes a misdemeanor, felony or a military offense. You may exclude misdemeanor traffic citations or convictions
involving driving under the influence (DUI) or driving while intoxicated (DWI), driving without a license, reckless driving, or driving with
a suspended or revoked license and juvenile offenses. “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 contendre or no contest, or having been given probation, a suspended sentence or a
fine.
If you answer yes, you must attach to this application:
a)
a written statement explaining the circumstances of each incident,
b)
a certified copy of the charging document, and
c)
a certified copy of the official document, which demonstrates the resolution of the charges or any final judgment.
If you have a felony conviction involving dishonesty or breach of trust, have you applied for written consent to engage in the Business
of insurance as required by 18 USC 1033?
N/A
Yes
No
If so, was consent granted? (Attach copy of 1033 consent.)
N/A
Yes
No
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?
“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, 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.
If you answer yes, you must attach to this application:
a)
a written statement identifying the type of license and explaining the circumstances of each incident,
b)
a certified copy of the Notice of Hearing or other document that states the charges and allegations, and
c)
a certified 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 you or any business in which you are or were an owner, partner, officer or director,
Yes
No
or member or manager of limited liability company, for overdue monies by an insurer, insured or producer, or have you ever been subject to a
bankruptcy proceeding?
If you answer yes, submit a written statement summarizing the details of the indebtedness and arrangements for repayment, and/or type and
location of bankruptcy and a current credit report.
4. Have you been notified by any jurisdiction to which you are applying of any delinquent tax obligation that is not the subject
Yes
No
of a repayment agreement?
If you answer yes, identify the jurisdiction(s): _______________________________________