"Life Producer Registration to Act as a Life Settlement Broker Individual Registration Form" - Connecticut

Life Producer Registration to Act as a Life Settlement Broker Individual Registration Form is a legal document that was released by the Connecticut Insurance Department - a government authority operating within Connecticut.

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Download "Life Producer Registration to Act as a Life Settlement Broker Individual Registration Form" - Connecticut

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STATE OF CONNECTICUT
INSURANCE DEPARTMENT
Life Producer Registration to Act as a Life Settlement Broker
Individual Registration Form
Registration fee: $26.00 check/money order payable to the “Treasurer, State of Connecticut”
Connecticut Producer License Number: ________________________________________________________________
-
-
Individual Social Security Number: _____________
_____________
____________
Individual Name: ___________________________________________________________________________________
Resident Address: _________________________________________________________________________________
Individual E-Mail: __________________________________________________________________________________
Work E-Mail: ______________________________________________________________________________________
Phone Number: (_____)_____________________________________________________________________________
I have continuously held an active Producer license with Life authority in my resident state for at least one year.
Yes _____ No_____
NOTE: Registration is not required if you hold an active Life Settlement Broker License in Connecticut.
APPLICANT’S CERTIFICATION AND ATTESTATION
The Applicant must read the following information carefully:
 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 license revocation or denial of the license and may subject me to civil
or criminal penalties.
 By signing this form, I agree to comply with CSG §38a-465 Life Settlements.
________________________________________________________________________________________________
Print or Type Name
_______________________________________________________________________
___________________
Signature
Date
Return to:
State of Connecticut
Insurance Department
Attn: Licensing
PO Box 816
Hartford, CT 06142-0816
Please allow 7-10 days for processing.
To check the status of the Registration:
From our homepage at www.ct.gov/cid, select “Verify and Print a License,” under “Industry.”
STATE OF CONNECTICUT
INSURANCE DEPARTMENT
Life Producer Registration to Act as a Life Settlement Broker
Individual Registration Form
Registration fee: $26.00 check/money order payable to the “Treasurer, State of Connecticut”
Connecticut Producer License Number: ________________________________________________________________
-
-
Individual Social Security Number: _____________
_____________
____________
Individual Name: ___________________________________________________________________________________
Resident Address: _________________________________________________________________________________
Individual E-Mail: __________________________________________________________________________________
Work E-Mail: ______________________________________________________________________________________
Phone Number: (_____)_____________________________________________________________________________
I have continuously held an active Producer license with Life authority in my resident state for at least one year.
Yes _____ No_____
NOTE: Registration is not required if you hold an active Life Settlement Broker License in Connecticut.
APPLICANT’S CERTIFICATION AND ATTESTATION
The Applicant must read the following information carefully:
 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 license revocation or denial of the license and may subject me to civil
or criminal penalties.
 By signing this form, I agree to comply with CSG §38a-465 Life Settlements.
________________________________________________________________________________________________
Print or Type Name
_______________________________________________________________________
___________________
Signature
Date
Return to:
State of Connecticut
Insurance Department
Attn: Licensing
PO Box 816
Hartford, CT 06142-0816
Please allow 7-10 days for processing.
To check the status of the Registration:
From our homepage at www.ct.gov/cid, select “Verify and Print a License,” under “Industry.”