Form DBO-1815 "Premium Finance Agency Application" - California

What Is Form DBO-1815?

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

Form Details:

  • Released on May 1, 2017;
  • The latest edition provided by the California Department of Business Oversight;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;

Download a fillable version of Form DBO-1815 by clicking the link below or browse more documents and templates provided by the California Department of Business Oversight.

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Download Form DBO-1815 "Premium Finance Agency Application" - California

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STATE OF CALIFORNIA – DEPARTMENT OF BUSINESS OVERSIGHT
PREMIUM FINANCE AGENCY APPLICATION
DBO-1815 (Rev. 5-17)
DEPARTMENT OF BUSINESS OVERSIGHT USE ONLY
BEFORE THE DEPARTMENT
Fee Paid $
OF BUSINESS OVERSIGHT
STATE OF CALIFORNIA
Receipt No.
File No.
In the Matter of an Application for the
)
Organization and Establishment of
Date:
)
)
(NAME OF INSTITUTION)
)
)
)
to Engage in Business as a Premium Finance Agency
)
)
____)
This application will not be filed unless accompanied by the statutory fee of Four Hundred Dollars ($400.00)
(Financial Code section 18115).
TO THE COMMISSIONER OF BUSINESS OVERSIGHT:
Application is hereby made for the written consent of the Commissioner of Business Oversight (the
“Commissioner”) to t h e proposed organization of a corporation to engage in the insurance premium
financing business as provided in California Financial Code, Division 7, Chapter 8 of the Industrial Loan Law
at __________________________________________________________________________in the city (or
(Proposed Street Location of Premium Finance Agency)
town) of __________________________________________
Zip Code____________________,
County of_____________________________________, State of California, such premium finance agency
to be known as ______________________________________________________________________
(Proposed Name of Premium Finance Agency)
APPLICANTS: The name and business occupations of all organizers or incorporators who are
forming this corporation are:
Name
Business or Occupation
_________________________________________
____________________________________________
_________________________________________
____________________________________________
_________________________________________
____________________________________________
_________________________________________
____________________________________________
STATE OF CALIFORNIA – DEPARTMENT OF BUSINESS OVERSIGHT
PREMIUM FINANCE AGENCY APPLICATION
DBO-1815 (Rev. 5-17)
DEPARTMENT OF BUSINESS OVERSIGHT USE ONLY
BEFORE THE DEPARTMENT
Fee Paid $
OF BUSINESS OVERSIGHT
STATE OF CALIFORNIA
Receipt No.
File No.
In the Matter of an Application for the
)
Organization and Establishment of
Date:
)
)
(NAME OF INSTITUTION)
)
)
)
to Engage in Business as a Premium Finance Agency
)
)
____)
This application will not be filed unless accompanied by the statutory fee of Four Hundred Dollars ($400.00)
(Financial Code section 18115).
TO THE COMMISSIONER OF BUSINESS OVERSIGHT:
Application is hereby made for the written consent of the Commissioner of Business Oversight (the
“Commissioner”) to t h e proposed organization of a corporation to engage in the insurance premium
financing business as provided in California Financial Code, Division 7, Chapter 8 of the Industrial Loan Law
at __________________________________________________________________________in the city (or
(Proposed Street Location of Premium Finance Agency)
town) of __________________________________________
Zip Code____________________,
County of_____________________________________, State of California, such premium finance agency
to be known as ______________________________________________________________________
(Proposed Name of Premium Finance Agency)
APPLICANTS: The name and business occupations of all organizers or incorporators who are
forming this corporation are:
Name
Business or Occupation
_________________________________________
____________________________________________
_________________________________________
____________________________________________
_________________________________________
____________________________________________
_________________________________________
____________________________________________
STATE OF CALIFORNIA – DEPARTMENT OF BUSINESS OVERSIGHT
PREMIUM FINANCE AGENCY APPLICATION
DBO-1815 (Rev. 5-17) Page 2 of 5
The applicant who is making this filing, and to whom all requests and correspondence is to be directed is:
Name
Business Address
Telephone Number
GENERAL INSTRUCTIONS
The following information shall be furnished as exhibits on separate sheets. The reference to each exhibit
should be shown in the space provided on this form. Please file the original application and a second
copy, including all attachments.
1. Corporate Form
a. Exhibit 1. A certificate of reservation of the proposed name to be obtained from the California
Secretary of State pursuant to Government Code section 12199.
b. Exhibit 2. A draft of the proposed Articles of Incorporation (See Financial Code sections 18100,
18101, and 18581).
c. Exhibit 3. A draft of the proposed bylaws.
2. Management
a. Exhibit 4. A listing of all incorporators and all proposed officers, directors, shareholders and
managing personnel. Arrange in the following order with appropriate titles and/or designations:
INCORPORATOR OFFICER
SHARE -
NAME
DIRECTOR
MANAGER
(Title)
HOLDER
b. Exhibits
to
. Interagency Biographical and Financial Report for each person listed above.
c. Exhibits
to
. A stock purchase questionnaire (on Form DFI 1802) for each person,
including corporate shareholder(s), listed in 2(a) above.
d. Exhibits
to
. An affidavit of each person listed in 2(a) above, who will be active in the
management and supervision of the premium finance agency, to the effect that he/she has read and
is familiar with the Industrial Loan Law and the Commissioner’s Rules relative to Insurance Premium
Financing. (Refer to California Financial Code Section 18000 et seq. and California Code of
Regulations, Title 10.)
STATE OF CALIFORNIA – DEPARTMENT OF BUSINESS OVERSIGHT
PREMIUM FINANCE AGENCY APPLICATION
DBO-1815 (Rev. 5-17) Page 3 of 5
3. Capitalization and Ownership
a. Exhibit
.
A schedule of the proposed capital structure of the applicant, including the
amount of authorized capital and the number and par value of shares authorized.
The
schedule shall also include the number of shares to be sold initially, the sale price per share, and
the total amount per share to be credited to paid-in surplus (if any). (Refer to Financial Code
section 18582.)
b. Exhibit
. If the applicant is to be owned in whole or in part by any corporation, partnership,
or other business form, identify all affiliates, their ownership, location and nature of business.
Also identify all officers and directors of these companies who are to be officers or directors of
the applicant. An organizational chart of all subsidiaries and affiliates should also be filed.
c. Exhibit
.
A list giving the names of the prospective stockholders and the number of
shares to be purchased by each.
4. Business Plan
a. Exhibit
. A detailed narrative statement of the applicant’s proposed plan of business which
should set forth both the business in which the applicant proposes to engage at the outset and its
plan for the future, including information relating to any plans the applicant may have for the
establishment of the branch offices. Full particulars should be given so that the Commissioner
will be fully informed as to just what the applicant is to do and how it proposes to do it.
b. Exhibit
. A statement as to whether or not there also shall be conducted on the premises
any other business. If so, furnish full and complete details. (Refer to Financial Code section
18344.)
c. Exhibit
. An estimate of the number and amount of premium financing loans expected to be
made in each of the first twelve months of operations.
d. Exhibit
.
A statement as to how the applicant proposes to handle the insured’s down
payment and how it will meet the requirements of Financial Code sections 18592 and 18593.
e.
Exhibit
. A statement describing applicant’s plans for issuing investment certificates.
(Refer to Financial Code sections 18560 and 18596.)
5.
Public Convenience and Advantage
[Refer to Financial Code sections 18116(b), 18116(c), and 18117(a)]
a. Exhibit
. A statement defining the boundaries of the community to be served, or the specific
group or groups of the public or insurance producers to be served. This commentary must
include a description of how the applicant’s business will be solicited – whether by mail, director
contact, through insurance agents or brokers, or through insurance companies.
Also state
how and why the new applicant’s services are needed in the community, and how the
applicant’s clients will benefit.
b. Exhibits
to
. Furnish relevant facts, statistics, or studies which applicant has used to
arrive at its conclusion that the convenience and advantage of the public will be promoted by
the establishment of the proposed insurance premium finance agency.
STATE OF CALIFORNIA – DEPARTMENT OF BUSINESS OVERSIGHT
PREMIUM FINANCE AGENCY APPLICATION
DBO-1815 (Rev. 5-17)
Page 4 of 5
6. Customer Authorization of Disclosure
a. Exhibit
. Customer Authorization of Disclosure of Financial Records. Complete attached
Form DFI 1821 (3/02) in accordance with the instructions given on attached Form DFI 1820
(3/02).
All materials submitted in connection with the application will be considered public information, unless
confidential treatment is requested pursuant to section 250.10, title 10, California Code of
Regulations, and the confidential treatment is confirmed in writing by this Department.
Applicants are aware of Labor Code section 3700, which requires every employer to be insured
against liability for workman’s compensation.
Applicants understand that supplemental information submitted by them orally may not be considered
a part of the application, unless it is confirmed in writing and incorporated into the application by
reference.
Applicants understand that the Commissioner shall not approve the application, unless he/she shall
ascertain to his/her satisfaction that all the requirements of Financial Code section 18117 have been met.
Each of the undersigned applicants certifies that he/she has read this application, including all
documents incorporated therein by reference, that he/she knows the contents thereof, and that the
statements therein are true and correct.
WHEREFORE, your applicants pray the application will be filed and that the Commissioner of
Business Oversight give his/her written consent to the proposed insurance premium finance agency as
set forth herein.
By
By
(Applicant)
(Applicant)
By
By
(Applicant)
(Applicant)
By
By
(Applicant)
(Applicant)
Executed on
, 20
, at
, California.
I certify (or declare) under penalty of perjury that the foregoing is true and correct.
Signature of Declarant:
(Note: This is a sample format of an application under Financial Code Section 18115 for approval of an
application for authority to engage in insurance premium finance business.
This sample is provided
only as an illustration of the format of an application. Refer to the requirements of Financial Code
Sections 18115, et seq.)
STATE OF CALIFORNIA – DEPARTMENT OF BUSINESS OVERSIGHT
PREMIUM FINANCE AGENCY APPLICATION
DBO-1815 (Rev. 5-17)
Page 5 of 5
DBO’s Privacy Notice on Collection
DBO Collects and Uses Personal Information: The DBO collects the information requested on this form as authorized by Chapter
1 of Title 10 of the California Code of Regulations. The DBO uses this information to process an application for the organization of a
corporation to engage in the insurance premium financing business pursuant to Division 7 of the Financial Code. Use of the
personal Information DBO collects is subject to limitations contained in the Information Practices Act of 1977 and other applicable
state and federal laws.
Providing Personal Information Is Mandatory: When providing information or documents, please do not include unrequested
personal information such as a Social Security number, driver’s license number, or financial information.
DBO May Disclose Your Personal Information: We may share your personal information with other federal and state financial
institution regulators, or any law enforcement agency. Your personal information may also be disclosed:
In response to a Public Records Act request, as allowed by the Information Practices Act.
To another governmental agency as required by state or federal law.
In response to a court order or administrative order, a subpoena or a search warrant.
Your Access to Your Personal Information: You may review the records maintained by DBO that contain your personal
information. To request access, contact: DBO Privacy Officer, 1515 K Street, Sacramento, CA 95814, (866) 275-2677.