"Rental Car Agency Permit Application Form" - Connecticut

Rental Car Agency Permit Application Form is a legal document that was released by the Connecticut Insurance Department - a government authority operating within Connecticut.

Form Details:

  • Released on October 12, 2016;
  • The latest edition currently provided by the Connecticut Insurance Department;
  • Ready to use and print;
  • Easy to customize;
  • 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 "Rental Car Agency Permit Application Form" - Connecticut

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STATE OF CONNECTICUT
INSURANCE DEPARTMENT
Rental Car Agency Permit
Ma ke ch e ck p a ya b le to : “T rea su re r, s ta te o f Co n n ect icu t ”
Fe e: $ 8 0 .0 0
Instructions:
1. Complete Application: incomplete applications will be returned
2. Sign and date application
3. Forward the appointment application(s) to the Insurance Company(ies) for which you will be
transacting business
4. The Insurance Company must complete the Rental Car Agency Company Appointment
Application and return the form to you. The Insurance Company emails or faxes the completed
form to you.
5. Attach the completed Rental Car Agency Company Appointment Application to this application
6. Submit both applications with payment. Check or Money Order for $80.00 payable to:
“Treasurer, State of Connecticut.”
(Note: The Department does not accept credit card payments or online applications for this
permit.)
7. Mail to:
Regular Mail
Overnight Mail:
State of Connecticut, Insurance Department
State of Connecticut, Insurance Department
Attention: Licensing
Attn: Licensing
th
PO Box 816
153 Market Street, 7
Floor
Hartford, CT 06142-0816
Hartford, CT 06103
(Please Print Cleary or Type)
1. Rental Car Agency Name:
________________________________________________________________________
2. Mailing Address (Address, City, State and Zip Code):
________________________________________________________________________
3. Physical Address (This address cannot be a PO Box):
________________________________________________________________________
4. Phone Number:
__(_____)________________________________________________________
5. Email:
________________________________________________________________________
6. Federal Tax-Id Number:
__________________________________________________________
www.ct.gov/cid
P.O. Box 816 Hartford, CT 06142-0816
An Equal Opportunity Employer
Rental Car Agency Permit (Revised: 10/12/2016)
P a g e
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STATE OF CONNECTICUT
INSURANCE DEPARTMENT
Rental Car Agency Permit
Ma ke ch e ck p a ya b le to : “T rea su re r, s ta te o f Co n n ect icu t ”
Fe e: $ 8 0 .0 0
Instructions:
1. Complete Application: incomplete applications will be returned
2. Sign and date application
3. Forward the appointment application(s) to the Insurance Company(ies) for which you will be
transacting business
4. The Insurance Company must complete the Rental Car Agency Company Appointment
Application and return the form to you. The Insurance Company emails or faxes the completed
form to you.
5. Attach the completed Rental Car Agency Company Appointment Application to this application
6. Submit both applications with payment. Check or Money Order for $80.00 payable to:
“Treasurer, State of Connecticut.”
(Note: The Department does not accept credit card payments or online applications for this
permit.)
7. Mail to:
Regular Mail
Overnight Mail:
State of Connecticut, Insurance Department
State of Connecticut, Insurance Department
Attention: Licensing
Attn: Licensing
th
PO Box 816
153 Market Street, 7
Floor
Hartford, CT 06142-0816
Hartford, CT 06103
(Please Print Cleary or Type)
1. Rental Car Agency Name:
________________________________________________________________________
2. Mailing Address (Address, City, State and Zip Code):
________________________________________________________________________
3. Physical Address (This address cannot be a PO Box):
________________________________________________________________________
4. Phone Number:
__(_____)________________________________________________________
5. Email:
________________________________________________________________________
6. Federal Tax-Id Number:
__________________________________________________________
www.ct.gov/cid
P.O. Box 816 Hartford, CT 06142-0816
An Equal Opportunity Employer
Rental Car Agency Permit (Revised: 10/12/2016)
P a g e
| 1
7. List of ALL business locations of the applicant pertinent to this application:
If you need additional space, attach additional sheets of paper to the application
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
8. Has a training program been implemented for employees involved in the marketing of
insurance to renters, in accordance with the requirements of Connecticut Regulation
38a-799-5?
Yes ______
No ______
9. Please let the authorized insurance companies which the applicant will represent:
If you need additional space, attach additional sheets of paper to the application
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
The permit fee of $80.00, the completed Rental Car Agency Company Appointment
Application must be included with this application. Make checks payable to: “Treasurer,
State of Connecticut.”
As an officer, partner, owner or principal of the applicant, I acknowledge that the
information contained herein is true and complete to the best of my knowledge and
belief, and I hereby agree to comply with the requirements set forth in C.G.S. 38a-799.
____________________________________
Print or Type Applicant Signature and Title
____________________________________
Signature/Date of Authorized Applicant
Rental Car Agency Permit (Revised: 10/12/2016)
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