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

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

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STATE OF CONNECTICUT
INSURANCE DEPARTMENT
Life Producer Registration to Act as a Life Settlement Broker
Business Entity Registration Form
Registration Fee: $26.00 check/money order payable to the “Treasurer, State of Connecticut”
Connecticut Producer License Number: ________________________________________________________________
-
-
Business Entity Federal Tax-ID Number: _____________
_____________
____________
Business Entity Name: ______________________________________________________________________________
Physical Address: __________________________________________________________________________________
E-Mail: ___________________________________________________________________________________________
Phone Number: (_____)_____________________________________________________________________________
Contact Information (Name, E-Mail and Phone Number): ___________________________________________________
_________________________________________________________________________________________________
APPL
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.
ICANT’S CE
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 Name
(Owner, Partner, Officer or Director)
________________________________________________________________________
___________________
Signature (Owner, Partner, Officer or Director)
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
Business Entity Registration Form
Registration Fee: $26.00 check/money order payable to the “Treasurer, State of Connecticut”
Connecticut Producer License Number: ________________________________________________________________
-
-
Business Entity Federal Tax-ID Number: _____________
_____________
____________
Business Entity Name: ______________________________________________________________________________
Physical Address: __________________________________________________________________________________
E-Mail: ___________________________________________________________________________________________
Phone Number: (_____)_____________________________________________________________________________
Contact Information (Name, E-Mail and Phone Number): ___________________________________________________
_________________________________________________________________________________________________
APPL
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.
ICANT’S CE
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 Name
(Owner, Partner, Officer or Director)
________________________________________________________________________
___________________
Signature (Owner, Partner, Officer or Director)
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.”