"Uniform Application for Business Entity License/Registration"

Uniform Application for Business Entity License/Registration is a 6-page legal document that was released by the National Association of Insurance Commissioners and used nation-wide.

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Please note the application may be revised on a bi-annual basis. To ensure you are filing the current version of the application, please
reference the National Insurance Producer Registry web site at www.nipr.com.
Uniform Application for
Business Entity License/Registration
(Please Print or Type)
Check appropriate boxes for license requested.
Resident License
Non-Resident License
Identify Home State:_______________
o
Identify Home State License #:_____________
o
New Application
Additional Line(s) of Authority
Demographic Information
Business Entity Name
2
Incorporation/Formation Date
3
FEIN
1
(month) ___(day) ___(year) _____
-
4
If assigned, National Producer Number (NPN)
If applicable, FINRA Firm Central Registration Depository (CRD)
5
List any other assumed, fictitious, alias or trade names under which you are currently
State of Domicile
Country of Domicile
7
8
6
doing business or intend to do business.
Is the business entity affiliated with a financial institution/bank?
Yes
No
9
10
Business Address
11
City
12
State
Zip Code
14
Foreign Country
13
Phone Number (include Ext.)
Fax Number
Business Web Site Address
Business E-Mail Address
15
16
17
18
(
)
-
(
)
-
Mailing Address
P.O. Box
City
State
Zip Code
Foreign Country
19
20
22
23
24
21
Designated/Responsible Licensed Producer
Identify at least one Designated/Responsible Licensed Producer responsible for the business entity’s compliance with the insurance laws, rules and regulations of this
25
state. (See Matrix of State Requirements at www.nipr.com for jurisdictions that require the designated/responsible licensed producer to be an officer, director or partner
of the business entity.)
-
-
NPN _______________________
Name
SSN
-
-
NPN________________________
Name
SSN
-
-
NPN________________________
Name
SSN
-
-
NPN________________________
Name
SSN
Owners, Partners, Officers and Directors
26
Identify all owners with 10% interest or voting interest, partners, officers and directors of the business entity, or members or managers of a limited liability company:
Name
Title
SSN/FEIN
-
-
D.O.B ___________Owner: Yes / No % of ownership interest ____
Name
Title
SSN/FEIN
-
-
D.O.B ___________Owner: Yes / No % of ownership interest ____
Name
Title
SSN/FEIN
-
-
D.O.B ___________Owner: Yes / No % of ownership interest ____
Name
Title
SSN/FEIN
-
-
D.O.B ___________Owner: Yes / No % of ownership interest ____
Name
Title
SSN/FEIN
-
-
D.O.B ___________Owner: Yes / No % of ownership interest ____
Name
Title
SSN/FEIN
-
-
D.O.B ___________Owner: Yes / No % of ownership interest ____
Name
Title
SSN/FEIN
-
-
D.O.B ___________Owner: Yes / No % of ownership interest ____
Name
Title
SSN/FEIN
-
-
D.O.B ___________Owner: Yes / No % of ownership interest ____
(State Use)
© 2014 National Association of Insurance Commissioners
Page 1 of 6
Please note the application may be revised on a bi-annual basis. To ensure you are filing the current version of the application, please
reference the National Insurance Producer Registry web site at www.nipr.com.
Uniform Application for
Business Entity License/Registration
(Please Print or Type)
Check appropriate boxes for license requested.
Resident License
Non-Resident License
Identify Home State:_______________
o
Identify Home State License #:_____________
o
New Application
Additional Line(s) of Authority
Demographic Information
Business Entity Name
2
Incorporation/Formation Date
3
FEIN
1
(month) ___(day) ___(year) _____
-
4
If assigned, National Producer Number (NPN)
If applicable, FINRA Firm Central Registration Depository (CRD)
5
List any other assumed, fictitious, alias or trade names under which you are currently
State of Domicile
Country of Domicile
7
8
6
doing business or intend to do business.
Is the business entity affiliated with a financial institution/bank?
Yes
No
9
10
Business Address
11
City
12
State
Zip Code
14
Foreign Country
13
Phone Number (include Ext.)
Fax Number
Business Web Site Address
Business E-Mail Address
15
16
17
18
(
)
-
(
)
-
Mailing Address
P.O. Box
City
State
Zip Code
Foreign Country
19
20
22
23
24
21
Designated/Responsible Licensed Producer
Identify at least one Designated/Responsible Licensed Producer responsible for the business entity’s compliance with the insurance laws, rules and regulations of this
25
state. (See Matrix of State Requirements at www.nipr.com for jurisdictions that require the designated/responsible licensed producer to be an officer, director or partner
of the business entity.)
-
-
NPN _______________________
Name
SSN
-
-
NPN________________________
Name
SSN
-
-
NPN________________________
Name
SSN
-
-
NPN________________________
Name
SSN
Owners, Partners, Officers and Directors
26
Identify all owners with 10% interest or voting interest, partners, officers and directors of the business entity, or members or managers of a limited liability company:
Name
Title
SSN/FEIN
-
-
D.O.B ___________Owner: Yes / No % of ownership interest ____
Name
Title
SSN/FEIN
-
-
D.O.B ___________Owner: Yes / No % of ownership interest ____
Name
Title
SSN/FEIN
-
-
D.O.B ___________Owner: Yes / No % of ownership interest ____
Name
Title
SSN/FEIN
-
-
D.O.B ___________Owner: Yes / No % of ownership interest ____
Name
Title
SSN/FEIN
-
-
D.O.B ___________Owner: Yes / No % of ownership interest ____
Name
Title
SSN/FEIN
-
-
D.O.B ___________Owner: Yes / No % of ownership interest ____
Name
Title
SSN/FEIN
-
-
D.O.B ___________Owner: Yes / No % of ownership interest ____
Name
Title
SSN/FEIN
-
-
D.O.B ___________Owner: Yes / No % of ownership interest ____
(State Use)
© 2014 National Association of Insurance Commissioners
Page 1 of 6
Please note the application may be revised on a bi-annual basis. To ensure you are filing the current version of the application, please
reference the National Insurance Producer Registry web site at www.nipr.com.
Uniform Application for
Business Entity License/Registration
Applicant Name: _______________________________
Jurisdiction and Type of License/Registration Requested –Major Lines of Authority
27
Next to each jurisdiction, check the legal business type, license/registration type(s) and line(s) of authority for which you are applying.
LLP – Limited Liability
Legal Business Type:
C – Corporation
P – Partnership
S – Sole Proprietorship
LLC – Limited Liability Company
Partnership
License/Registration
A – Agent
B – Broker
P – Producer
SLP – Surplus Lines Producer
Types:
V – Variable
H – Accident & Health or
Lines of Authority:
L – Life
P – Property
C – Casualty
P L– Personal Lines
Life/Variable Annuity
Sickness
Jurisdiction
Legal Business Type
License/Registration Type
Lines of Authority
C
P
S
LLC
LLP
A
B
P
SLP
V
L
H
P
C
PL
AK
AL
AR
AZ
CA
CO
CT
DC
DE
FL
GA
GU
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
PR
RI
SC
SD
TN
TX
UT
VA
VI
VT
WA
WI
WV
WY
© 2014 National Association of Insurance Commissioners
Page 2 of 6
Please note the application may be revised on a bi-annual basis. To ensure you are filing the current version of the application, please
reference the National Insurance Producer Registry web site at www.nipr.com.
Uniform Application for
Business Entity License/Registration
Applicant Name:______________________________________
Jurisdiction and Type of License/Registration - Limited Lines of Authority
28
Next to each jurisdiction, check the legal business type, license/registration type(s) and line(s) of authority for which you are applying.
LLP – Limited Liability
Legal Business Type:
C – Corporation
P – Partnership
S – Sole Proprietorship
LLC – Limited Liability Company
Partnership
License/Registration
A – Agent
B – Broker
P – Producer
SLP – Surplus Lines Producer
Types :
Limited Lines:
Credit – Credit
CR – Car Rental
CROP – Crop
T – Travel
S – Surety
O – Other: Specify Type
Jurisdiction
Legal Business Type
License/Registration Type
Lines of Authority
C
P
S
LLC
LLP
A
B
P
SLP
Credit
CR
Crop
T
S
O____________
AK
AL
AR
AZ
CA
CO
CT
DC
DE
FL
GA
GU
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
PR
RI
SC
SD
TN
TX
UT
VA
VI
VT
WA
WI
WV
WY
© 2014 National Association of Insurance Commissioners
Page 3 of 6
Please note the application may be revised on a bi-annual basis. To ensure you are filing the current version of the application, please
reference the National Insurance Producer Registry web site at www.nipr.com.
Uniform Application for
Business Entity License/Registration
Applicant Name:______________________________________
Background Questions
Please read the following very carefully and answer every question. All written statements submitted by the Applicant must include an
29
original signature.
1a. Has the business entity or any owner, partner, officer or director of the business entity, or member or manager of a limited liability
company, ever been convicted of a misdemeanor, had a judgment withheld or deferred or is the business entity or any owner, partner,
officer or director of the business entity, or member or manager currently charged with, committing a misdemeanor?
Yes ___ No___
You may exclude the following misdemeanor convictions or pending misdemeanor charges: traffic citations, driving under the influence
(DUI) or 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 juvenile court.)
1b. Has the business entity or any owner, partner, officer or director of the business entity, or member or manager of a limited liability
company ever been convicted of a felony, had judgment withheld or deferred, or is the business entity or any owner, partner, officer or
director of the business entity or member or manager of a limited liability company currently charged with committing a felony?
Yes ___ No___
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 consent granted? (Attach copy of 1033 consent approved by home state.)
N/A___ Yes ____ No____
1c. Has the business entity or any owner, partner, officer or director of the business entity or member or manager of a limited liability
company, ever been convicted of a military offense, had a judgment withheld or deferred, or is the business entity or any owner, partner,
officer or director of the business entity or member or manager of a limited liability company, currently charged with committing a
Yes ___ No___
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 identifying all parties involved (including their percentage of ownership, if any) and explaining the
circumstances of each incident,
b) a copy of the charging document,
c) a copy of the official document which demonstrates the resolution of the charges or any final judgment.
2. Has the business entity or any owner, partner, officer or director of the business entity, or manager or member of a limited liability
company, ever been named or involved as a party in an administrative proceeding, including a 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 application denied or the act of withdrawing an application
to avoid a denial. 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, all parties involved (including their percentage of ownership, if any) 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 the business entity or any owner, partner, officer or director of the business
entity, 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.
N/A___Yes ___ No___
If you answer yes, submit a statement summarizing the details of the indebtedness and arrangements for repayment.
4. Has the business entity or any owner, partner, officer or director of the business entity, or member or manager of a limited liability
company, ever 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): _______________________________________
© 2014 National Association of Insurance Commissioners
Page 4 of 6
Please note the application may be revised on a bi-annual basis. To ensure you are filing the current version of the application, please
reference the National Insurance Producer Registry web site at www.nipr.com.
Uniform Application for
Business Entity License/Registration
Applicant Name:______________________________________
5. Is the business entity or any owner, partner, officer or director of the business entity, or member or manager of a limited liability
company, a party to, or ever been found liable in any lawsuit or arbitration 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 arbitrations, or mediation proceedings and
c)
a copy of the official documents which demonstrates the resolution of the charges or any final judgment.
6. Has the business entity or any owner, partner, officer or director of the business entity, 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
b)
copies of all relevant documents.
7. In response to a “yes” answer to one or more of the Background Questions for this application, are you submitting document(s) to the
N/A___Yes ___ No___
NAIC/NIPR Attachments Warehouse?
If you answer yes:
Will you be associating (linking) previously filed documents from the NAIC/NIPR Attachments Warehouse to this application?
Yes ___ No___
Note: If you have previously submitted documents to the Attachments Warehouse that are intended to be filed with this application, you
must go to the Attachments Warehouse and associate (link) the supporting document(s) to this application based upon the particular
background question number you have answered yes to on this application. You will receive information in a follow-up page at the end of
the application process, providing a link to the Attachment Warehouse instructions.
© 2014 National Association of Insurance Commissioners
Page 5 of 6
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