"Portable Electronic Insurance License Application Form" - Connecticut

Portable Electronic Insurance License Application Form is a legal document that was released by the Connecticut Insurance Department - a government authority operating within Connecticut.

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Download "Portable Electronic Insurance License Application Form" - Connecticut

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STATE OF CONNECTICUT
INSURANCE DEPARTMENT
Portable Electronic Insurance License Application
Fee: $600.00
Make check payable to:
Treasurer, State of Connecticut
Instructions:
Application: Each section of this application must be completed, signed and dated by the Designated Individual.
Incomplete applications will be returned.
Documentation: Any required documents must be sent with the application.
(Note: Review of an application will not begin until all required documentation has been received by the
Department.)
Fee: $600.00
Payment Method: Only Checks or Money Orders are accepted. Make payable to: “Treasurer, State of
Connecticut.”
(The Department does not accept cash or credit card payments for this license type.)
Completion of the Application: Please print clearly or type all requested information on the application.
Processing Time: Please allow 7-10 days for processing
Verify and Print a License: From our homepage at www.ct.gov/cid, select “Verify and Print a License,” under
“Industry.”
Regular Mail
Overnight Mail
State of Connecticut
State of Connecticut
Insurance Department
Insurance Department
Attn: Licensing
Attn: Licensing
th
PO Box 816
153 Market Street, 7
Floor
Hartford, CT 06142-0816
Hartford, CT 06103
Portable Electronic Insurance License Application
(Section A)
Business Entity Name: ______________________________________________________________________________
Federal Tax Identification Number (FEIN): _________-__________-_________
Address of Principal Office:
_______________________________________________________________________
(Street)
_______________________________________________________________________
(City)
(State)
(Zip Code)
Mailing Address: ___________________________________________________________________________________
(Street)
___________________________________________________________________________________
(City)
(State)
(Zip Code)
Phone Number: (______) _________________________________________________ (Extension): ________________
Email Address: ____________________________________________________________________________________
STATE OF CONNECTICUT
INSURANCE DEPARTMENT
Portable Electronic Insurance License Application
Fee: $600.00
Make check payable to:
Treasurer, State of Connecticut
Instructions:
Application: Each section of this application must be completed, signed and dated by the Designated Individual.
Incomplete applications will be returned.
Documentation: Any required documents must be sent with the application.
(Note: Review of an application will not begin until all required documentation has been received by the
Department.)
Fee: $600.00
Payment Method: Only Checks or Money Orders are accepted. Make payable to: “Treasurer, State of
Connecticut.”
(The Department does not accept cash or credit card payments for this license type.)
Completion of the Application: Please print clearly or type all requested information on the application.
Processing Time: Please allow 7-10 days for processing
Verify and Print a License: From our homepage at www.ct.gov/cid, select “Verify and Print a License,” under
“Industry.”
Regular Mail
Overnight Mail
State of Connecticut
State of Connecticut
Insurance Department
Insurance Department
Attn: Licensing
Attn: Licensing
th
PO Box 816
153 Market Street, 7
Floor
Hartford, CT 06142-0816
Hartford, CT 06103
Portable Electronic Insurance License Application
(Section A)
Business Entity Name: ______________________________________________________________________________
Federal Tax Identification Number (FEIN): _________-__________-_________
Address of Principal Office:
_______________________________________________________________________
(Street)
_______________________________________________________________________
(City)
(State)
(Zip Code)
Mailing Address: ___________________________________________________________________________________
(Street)
___________________________________________________________________________________
(City)
(State)
(Zip Code)
Phone Number: (______) _________________________________________________ (Extension): ________________
Email Address: ____________________________________________________________________________________
Portable Electronic Insurance License Application
(Section B)
Responsible Party Information
Designated Individual’s Name: ________________________________________________________________________
Designated Individual’s Title:__________________________________________________________________________
Resident Address:
_______________________________________________________________________________
(Street)
_________________________________________________________________________________________________
(City)
(State)
(Zip Code)
Phone Number: (_____) _____________________________________________________________________________
Email Address: ____________________________________________________________________________________
Supervising Entity
Insurer
OR
Producer
Name of Supervising Entity: __________________________________________________________________________
NAIC No. OR Connecticut Producer License No.:__________________________________________________________
Contact Person’s Name: _____________________________________________________________________________
Contact Person’s Address: ___________________________________________________________________________
(Street)
_________________________________________________________________________________________________
(City)
(State)
(Zip Code)
Contact Person’s Phone Number: (_____) _______________________________________________________________
Contact Person’s Email Address: ______________________________________________________________________
(Section C)
If the Entity derives more than 50% of its revenue from the sale of portable electronics insurance, complete
sections 1 and 2 below.
1. Below list all shareholders who directly or indirectly own 10% or more of any class of security:
Name: ________________________________________________________________________________________
Title: _________________________________________________________________________________________
Resident Address: ______________________________________________________________________________
(Street)
_____________________________________________________________________________________________
(City)
(State)
(Zip Code)
Phone Number: (____) ___________________________________________________________________________
Email Address: _________________________________________________________________________________
2
Portable Electronic Insurance License Application
Name: ________________________________________________________________________________________
Title: _________________________________________________________________________________________
Resident Address: ______________________________________________________________________________
(Street)
_____________________________________________________________________________________________
(City)
(State)
(Zip Code)
Phone Number: (____) ___________________________________________________________________________
Email Address: _________________________________________________________________________________
Name: ________________________________________________________________________________________
Title: _________________________________________________________________________________________
Resident Address: ______________________________________________________________________________
(Street)
_____________________________________________________________________________________________
(City)
(State)
(Zip Code)
Phone Number: (____) ___________________________________________________________________________
Email Address: _________________________________________________________________________________
(If additional Shareholders need to be added – Please attach on a separate sheet)
2. Below list all Officers and Directors of the entity:
Name: ________________________________________________________________________________________
Title: _________________________________________________________________________________________
Resident Address:
_____________________________________________________________________________________________
(Street)
_____________________________________________________________________________________________
(City)
(State)
(Zip Code)
Phone Number: (____) ___________________________________________________________________________
Email Address: _________________________________________________________________________________
Name: ________________________________________________________________________________________
Title: _________________________________________________________________________________________
Resident Address: ______________________________________________________________________________
(Street)
_____________________________________________________________________________________________
(City)
(State)
(Zip Code)
Phone Number: (____) ___________________________________________________________________________
Email Address: _________________________________________________________________________________
3
Portable Electronic Insurance License Application
Name: ________________________________________________________________________________________
Title: _________________________________________________________________________________________
Resident Address: ______________________________________________________________________________
(Street)
_____________________________________________________________________________________________
(City)
(State)
(Zip Code)
Phone Number: (____) ___________________________________________________________________________
Email Address: _________________________________________________________________________________
(If additional Officers and Directors need to be added – Please attach on a separate sheet)
4
Portable Electronic Insurance License Application
(Section D)
Applicant’s Certification and Attestation:
The Applicant must read the following very carefully:
1. All of the information submitted in this application and attachments is true and complete and I am aware that
submitting false information or omitting pertinent or material information in connection with this application is
grounds for license or registration revocation and may subject me and the business entity or limited liability
company to civil or criminal penalties.
2. Unless otherwise provided by Connecticut law or regulation, the business entity or limited liability company hereby
designates the Commissioner to be its agent for service of process regarding all insurance matters in the State of
Connecticut and agree that service upon the Commissioner is of the same legal force and validity as personal
service upon the business entity.
3. The business entity or limited liability company grants permission to the Insurance Commissioner to verify any
information supplied with any federal, state or local government agency, current or former employer of insurance
company.
4. I authorize the Commissioner, to give any information, as permitted by law, to any federal, state or municipal
agency, or any other organization and I release the State of Connecticut, Insurance Department and any person
acting on their behalf from any and all liability of whatever nature by reason of furnishing such information.
5. I acknowledge that I understand and comply with the insurance laws and regulations of the State of Connecticut,
Insurance Department.
6. I hereby certify that upon request, I will furnish the Commissioner, certified copies of any documents attached to
this application or requested by the Insurance Department.
7. I will certify that the Designated Individual(s) named on this application understands that he/she is responsible for
the business entity’s compliance with the insurance laws, rules and regulation of the State of Connecticut.
Must be signed by a Designated Individual of the business entity or Limited Liability Company
______________________________________________
(Full Legal Name – Print or Typed)
______________________________________________
(Original Designated Individual’s Signature)
______________________________________________
(Month/Day/Year)
______________________________________________
(Title)
______________________________________________
(Address)
______________________________________________
(City)
(State)
(Zip)
5
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