"Application for Individual Fraternal Agent License/Appointment" - Connecticut

Application for Individual Fraternal Agent License/Appointment is a legal document that was released by the Connecticut Insurance Department - a government authority operating within Connecticut.

Form Details:

  • Released on March 4, 2016;
  • The latest edition currently provided by the Connecticut Insurance Department;
  • Ready to use and print;
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  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

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

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Download "Application for Individual Fraternal Agent License/Appointment" - Connecticut

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STATE OF CONNECTICUT INSURANCE DEPARTMENT
Fee: $130
Application for Individual
Fraternal Agent License/Appointment
Make check payable to: “Treasurer, State of Connecticut”
(Please Print or Type)
1. Soc. Security Number
2. Date of Birth
3. Gender (Circle One)
(month) _____ (day) _____ (year) _____
Male / Female
4.Last Name
Jr./Sr. etc
5. First Name
6. Middle Name
7. Residence/Home Address (Physical Street)
8. City
9. State
10. Zip
12. Home Phone Number
13. Individual Email
14. Are you a citizen of the United States?
(Check One)
Yes ___
No ___
(
)
-
(If No, you must supply work authorization.)
15. Business Name
16. Business Address (Physical Address)
17. City
18. State
19. Zip
21. Business Phone Number
22. Business Fax Number
23. Business E-mail
24. Business Website
(include extension)
(
)
-
(
)
-
25. Applicant’s Mailing Address
25. City
26. State
27. Zip
(Include PO Box if required)
LINES OF AUTHORITY
29. Lines of authority requested by Fraternal Benefit Society: (Check all lines of authority requesting)
Life
Accident & Health
Variable Annuities
Variable Life
CERTIFICATION TO BE COMPLETED BY THE FRATERNAL BENEFIT SOCIETY
30. Name of Society: _____________________________________________________________________________________________
Address of Society: ___________________________________________________________________________________________
Society Contact Email: ________________________________________________________________________________________
The undersigned, being a Fraternal Benefit Society authorized to transact fraternal insurance in the State of Connecticut, certifies that
the above named individual will be appointed as a fraternal agent of this Society, if the license applied for is issued by the Insurance
Commissioner, and that this Society after investigation, has completely satisfied itself that the individual is trustworthy and completely
reliable.
__________________________________________
______________________________________________________________
Month
Day
Year
Certified By
_________________________________________________________________________________
Name and Title (Printed or Typed)
__________________________________________________________________________________________
Email (Print or Typed)
OCCUPATION
31. Present Occupation _____________________________________
Employer _____________________________________
What percentage of your time do you devote, or intend to devote, to the solicitation of Fraternal Insurance? _______________%
CID Stock # 1207-06
Page 1 of 3
(Revised 03/04/2016)
STATE OF CONNECTICUT INSURANCE DEPARTMENT
Fee: $130
Application for Individual
Fraternal Agent License/Appointment
Make check payable to: “Treasurer, State of Connecticut”
(Please Print or Type)
1. Soc. Security Number
2. Date of Birth
3. Gender (Circle One)
(month) _____ (day) _____ (year) _____
Male / Female
4.Last Name
Jr./Sr. etc
5. First Name
6. Middle Name
7. Residence/Home Address (Physical Street)
8. City
9. State
10. Zip
12. Home Phone Number
13. Individual Email
14. Are you a citizen of the United States?
(Check One)
Yes ___
No ___
(
)
-
(If No, you must supply work authorization.)
15. Business Name
16. Business Address (Physical Address)
17. City
18. State
19. Zip
21. Business Phone Number
22. Business Fax Number
23. Business E-mail
24. Business Website
(include extension)
(
)
-
(
)
-
25. Applicant’s Mailing Address
25. City
26. State
27. Zip
(Include PO Box if required)
LINES OF AUTHORITY
29. Lines of authority requested by Fraternal Benefit Society: (Check all lines of authority requesting)
Life
Accident & Health
Variable Annuities
Variable Life
CERTIFICATION TO BE COMPLETED BY THE FRATERNAL BENEFIT SOCIETY
30. Name of Society: _____________________________________________________________________________________________
Address of Society: ___________________________________________________________________________________________
Society Contact Email: ________________________________________________________________________________________
The undersigned, being a Fraternal Benefit Society authorized to transact fraternal insurance in the State of Connecticut, certifies that
the above named individual will be appointed as a fraternal agent of this Society, if the license applied for is issued by the Insurance
Commissioner, and that this Society after investigation, has completely satisfied itself that the individual is trustworthy and completely
reliable.
__________________________________________
______________________________________________________________
Month
Day
Year
Certified By
_________________________________________________________________________________
Name and Title (Printed or Typed)
__________________________________________________________________________________________
Email (Print or Typed)
OCCUPATION
31. Present Occupation _____________________________________
Employer _____________________________________
What percentage of your time do you devote, or intend to devote, to the solicitation of Fraternal Insurance? _______________%
CID Stock # 1207-06
Page 1 of 3
(Revised 03/04/2016)
BACKGROUND INFORMATION
32. The Applicant must read the following very carefully and answer every question. All written statements submitted
by the Applicant must include an original signature.
1a. Have you ever been convicted of a misdemeanor, had a judgment withheld or deferred, or are you currently charged with,
committing a crime?
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 a
felony?
You may exclude juvenile adjudications (offenses where you were adjudicated delinquent in a juvenile court).
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 in your home state as required by 18 USC 1033?
N/A___ Yes___ No___
If so, was that consent granted? (Attach copy of 1033 consent approved by home state.)
N/A___ Yes___ No___
1c. Have you ever been convicted of a military offense, had a judgment withheld or deferred, or are you currently charged with
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, and
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 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, a cease and desist order, a prohibition order, a
compliance order, 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.
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 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.
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 on behalf of
others.
Yes __ No __
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): _____________________________________________________________
CID Stock # 1207-06
Page 2 of 3
(Revised 03/04/2016)
5.
Are you currently a party to, or have you ever been found liable in, any lawsuit, arbitration or mediation proceeding involving
allegations of fraud, misappropriation or conversion of funds, misrepresentation or breach of fiduciary duty?
Yes __ No __
If you answer yes, you must attach to this application:
a) a written statement summarizing the details of each incident,
b) a copy of the Petition, Complaint or other document that commenced the lawsuit or arbitration, or mediation proceedings
and
c) a copy of the official documents, which demonstrates the resolution of the charges or any final judgment.
6.
Have 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 ever had an insurance agency contract or any other business relationship with an insurance company terminated for any
alleged misconduct?
Yes __ No __
If you answer yes, you must attach to this application:
a) a written statement summarizing the details of each incident and explaining why you feel this incident should not
prevent you from receiving an insurance license, and
copies of all relevant documents.
b)
7.
Do you have a child support obligation in arrearage?
Yes __ No __
If you answer yes,
a) by how many months are you in arrearage?
______Months
b) are you currently subject to and in compliance with any repayment agreement
Yes___ No___
c) are you the subject of a child support related subpoena/warrant?
Yes___ No___
If you answered yes, provide documentation showing proof of current payments or an approved repayment plan from the
appropriate state child support agency.
APPLICANT’S CERTIFICATION AND ATTESTATION
33. 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 license revocation or denial of the license 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 of Insurance, in
Connecticut to be my agent for service of process regarding all insurance matters in the respective jurisdiction and agree that service
upon the Commissioner of Insurance is of the same legal force and validity as personal service upon myself.
3. I further certify that I grant permission to the Commissioner of Insurance 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, either: a) I have no child-support obligation, or 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 Connecticut Insurance Department 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 Connecticut Insurance
Department 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 State of Connecticut.
7. For Non-Resident License Applications, I certify that I am licensed 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 Connecticut Insurance Department to which I am applying, certified copies of
any documents attached to this application or requested by the Connecticut Insurance Department.
____________________________________
___________________________________________
Month
Day
Year
Original Applicant Signature
___________________________________________
Full Legal Name (Printed or Typed)
Return Completed application and fee to: State of Connecticut, Insurance Department, PO Box 816, Hartford, CT 06142-0816
CID Stock # 1207-06
Page 3 of 3
(Revised 03/04/2016)
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