"Premium Finance Company Renewal Application Form" - Connecticut

Premium Finance Company Renewal 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 "Premium Finance Company Renewal Application Form" - Connecticut

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STATE OF CONNECTICUT
INSURANCE DEPARTMENT
Premium Finance Company Renewal Application
Name: ____________________________________________________________________________________________
Business Address: __________________________________________________________________________________
Mailing Address: ___________________________________________________________________________________
Contact Person: ____________________________________________________ Phone: (_____) ___________________
Email: ____________________________________________________________________________________________
Applicant Federal Tax ID# (Per C.G.S. 4a-79): ____________________________________________________________
This is the ONLY notice you will receive to renew your current license.
Your license to act as an Insurance Premium Finance Company will EXPIRE on JUNE 30, 2017. If you wish to renew
it, return both applications, completed and signed, to the Insurance Department, together with your check or money order
for $50.00, made payable to: “Treasurer, State of Connecticut.”
1. Does the Applicant intend to conduct the premium finance business under any other name(s)? If so, please provide
the name under which premium finance operations will be conducted:
______________________________________________________________________________________________
2. If a fictitious name is to be used to conduct the premium finance business, has the applicant complied with the
notification requirements of C.G.S. section 35-1?
______________________________________________________________________________________________
3. State whether applicant is an individual, partnership, association or corporation. Please provide the legal entity name
if different from #1 above:
______________________________________________________________________________________________
4. Does your Insurance Premium Finance Company have employees in Connecticut?
Yes___ No___
If you answered yes to the above question, please enclose a current certificate of worker’s compensation insurance.
(31-286A CGS)
STATE OF CONNECTICUT
INSURANCE DEPARTMENT
Premium Finance Company Renewal Application
Name: ____________________________________________________________________________________________
Business Address: __________________________________________________________________________________
Mailing Address: ___________________________________________________________________________________
Contact Person: ____________________________________________________ Phone: (_____) ___________________
Email: ____________________________________________________________________________________________
Applicant Federal Tax ID# (Per C.G.S. 4a-79): ____________________________________________________________
This is the ONLY notice you will receive to renew your current license.
Your license to act as an Insurance Premium Finance Company will EXPIRE on JUNE 30, 2017. If you wish to renew
it, return both applications, completed and signed, to the Insurance Department, together with your check or money order
for $50.00, made payable to: “Treasurer, State of Connecticut.”
1. Does the Applicant intend to conduct the premium finance business under any other name(s)? If so, please provide
the name under which premium finance operations will be conducted:
______________________________________________________________________________________________
2. If a fictitious name is to be used to conduct the premium finance business, has the applicant complied with the
notification requirements of C.G.S. section 35-1?
______________________________________________________________________________________________
3. State whether applicant is an individual, partnership, association or corporation. Please provide the legal entity name
if different from #1 above:
______________________________________________________________________________________________
4. Does your Insurance Premium Finance Company have employees in Connecticut?
Yes___ No___
If you answered yes to the above question, please enclose a current certificate of worker’s compensation insurance.
(31-286A CGS)
5. If partnership, association or corporation, please list partner, member, or officer changes below.
Name
If officer (title)
Resident Address
Business Address
Occupation
6. If Corporation, please list changes in directors.
Name
If officer (title)
Resident Address
Business Address
Occupation
If there are no changes listed in items #5 or #6, sign, date and notarize below. If there are changes listed in items #5 or
#6, sign, date and notarize below, and then complete item #7 (Biographical Affidavit) on the following page for each
individual reporting a change of information.
I, the applicant and/or the new individual, partner, director, member, officer, manager named above being duly sworn
according to law, depose and say that the answers set forth above are true to the best of my knowledge and belief.
_____________________________________________________________
Signature of Applicant
Date: _______________________
Sworn and subscribed to before me at:
______________________________________________________________________________
This_____________________________________ day of ________________________, 20_____.
______________________________________________________________ Notary
Public
7. Biographical Affidavit:
Complete this page only if there are changes listed in items #5 or #6.
Give the following information as to each new individual applicant, and, if the applicant is a partnership or
corporation, each new individual partner, member, officer, director and/or manager.
If needed, attach extra sheets.
A. Full Name: _____________________________________________________ Title: ___________________________
B. Date of Birth: ______________________ Place of Birth: _______________________________ Sex: _____________
C. Resident Address: ________________________________________________________________________________
D. Present Occupation: _______________________________________________________________________________
E. Employer:
_______________________________________________________________________________________
F. Are you licensed as an insurance agent?
Yes___ No___
If so, where, what kind of license and for what lines of Insurance? _________________________________________
G. Give name of any state where you are now and have been licensed to finance insurance premiums.
__________________________________________________________________________________________________
H. Have you ever been charged with, arrested, indicted for, or convicted of any offense against the laws of the United
States Government, any state or sub-division thereof, or any other jurisdiction?
Yes___ No___
If yes, give all details: ____________________________________________________________________________
____________________________________________________________________________
I. Has any department, public official or court at any time suspended, cancelled, revoked, or refused to issue or renew
any license or permit of any kind applied for by you or issued to you, to engage in the insurance business or to pursue
any other business, trade, calling or profession?
Yes___ No___
If yes, give all the details: _________________________________________________________________________
_________________________________________________________________________
I, the applicant and or the new individual, partner, director, member, officer, manager named above being duly sworn
according to law, depose and say that the answers set forth above are true to the best of my knowledge and belief.
________________________________________________
Signature of Applicant
Date: __________________________________
Sworn and subscribed to before me at _________________________________________________________
This _____________________________ day of __________________, 20_______.
_____________________________________________________
Notary Public
Department Contact: Email:
alan.sundell@ct.gov
Phone: (860) 297-3821
Fax: (860) 297-3978
Regular Mail:
State of CT, Insurance Dept., Attn: Maura Welch, PO Box 816, Hartford, CT 06142-0816
th
Overnight Mail:
State of CT, Insurance Dept., Attn: Maura Welch, 153 Market Street, 7
Floor, Hartford, CT 06103
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