"Insurance Producer License Renewal Form" - Nebraska

Insurance Producer License Renewal Form is a legal document that was released by the Nebraska Department of Insurance - a government authority operating within Nebraska.

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Download "Insurance Producer License Renewal Form" - Nebraska

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STATE OF NEBRASKA
For DOI Use Only
DEPARTMENT OF INSURANCE
Identifier # ______________
PO Box 82089
Amount ________________
Lincoln, NE 68501
Dist # _________________
www.doi.nebraska.gov
Check # ________________
MOTOR CLUB REPRESENTATIVE
INSURANCE PRODUCER
LICENSE RENEWAL FORM
REGISTRATION FORM
/
/
/
/
___
D.O.B:___
___
_____ Renewal Date:___
_
Name:_________________________ License #:__________
___
____
The Insurance
Producers
Licensing Act
requires
that
insurance producers
report criminal
and administrative
actions
to the Director of lnsurance. The
reporting requirements are
located
at Neb. Rev. Stat
§
44-4065.
1a.
Have
you been
convicted
of a
misdemeanor,
had a
judgment withheld
or
deferred,
or
are
YES ___ NO ___
you currently charged with
committing
a
misdemeanor,
which has not
been previously
reported
to
this
insurance department?
YES ___ NO ___
1b. Have you been convicted of a
felony,
had a
judgment withheld
or
deferred,
or
are
you
currently
charged
with committing
a felony, which has
not been
previously
reported to
this
insurance department?
1c.
Have you been convicted
of
a military
offense,
had
a judgment
withheld or
deferred, or are
YES ___ NO ___
you
currently
charged with
committing
a military
offense,
which
has not been previously
reported to
this insurance department?
** 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,
c) A copy
of
the
official
document,
which demonstrates the
resolution
of
the
charges
or any
final
judgment.
2. Have
you been named
or
involved as
a
party
in
an administrative
proceeding, including a
YES ___ NO ___
FINRA sanction or arbitration proceeding, regarding any
professional
or
occupational
license
or
registration,
which
has
not been
previously reported to
this insurance
department?
"Involved" means
having
a
license
censured, suspended, revoked,
canceled,
terminated
;
or, being
assessed a fine, 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.
Do you
have
a
child support
obligation
in
arrearage,
which has
not
been
previously
YES ___ NO ___
reported
to this
insurance department?
4.
In
response
to a
"yes"
answer
to
one or more of the
Background
Questions
for
this renewal
YES ___ NO ___
application, are
you
submitting document(s)
to the
NAIC/NIPR Attachments
Warehouse?
NA ___
5. Are
you
a
Citizen
of the
United
States?
If No,
you
must
provide proof
of
eligibility
to work
YES ___ NO ___
in
the United States.
Signature: ________________________________________
Date: _______________________
STATE OF NEBRASKA
For DOI Use Only
DEPARTMENT OF INSURANCE
Identifier # ______________
PO Box 82089
Amount ________________
Lincoln, NE 68501
Dist # _________________
www.doi.nebraska.gov
Check # ________________
MOTOR CLUB REPRESENTATIVE
INSURANCE PRODUCER
LICENSE RENEWAL FORM
REGISTRATION FORM
/
/
/
/
___
D.O.B:___
___
_____ Renewal Date:___
_
Name:_________________________ License #:__________
___
____
The Insurance
Producers
Licensing Act
requires
that
insurance producers
report criminal
and administrative
actions
to the Director of lnsurance. The
reporting requirements are
located
at Neb. Rev. Stat
§
44-4065.
1a.
Have
you been
convicted
of a
misdemeanor,
had a
judgment withheld
or
deferred,
or
are
YES ___ NO ___
you currently charged with
committing
a
misdemeanor,
which has not
been previously
reported
to
this
insurance department?
YES ___ NO ___
1b. Have you been convicted of a
felony,
had a
judgment withheld
or
deferred,
or
are
you
currently
charged
with committing
a felony, which has
not been
previously
reported to
this
insurance department?
1c.
Have you been convicted
of
a military
offense,
had
a judgment
withheld or
deferred, or are
YES ___ NO ___
you
currently
charged with
committing
a military
offense,
which
has not been previously
reported to
this insurance department?
** 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,
c) A copy
of
the
official
document,
which demonstrates the
resolution
of
the
charges
or any
final
judgment.
2. Have
you been named
or
involved as
a
party
in
an administrative
proceeding, including a
YES ___ NO ___
FINRA sanction or arbitration proceeding, regarding any
professional
or
occupational
license
or
registration,
which
has
not been
previously reported to
this insurance
department?
"Involved" means
having
a
license
censured, suspended, revoked,
canceled,
terminated
;
or, being
assessed a fine, 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.
Do you
have
a
child support
obligation
in
arrearage,
which has
not
been
previously
YES ___ NO ___
reported
to this
insurance department?
4.
In
response
to a
"yes"
answer
to
one or more of the
Background
Questions
for
this renewal
YES ___ NO ___
application, are
you
submitting document(s)
to the
NAIC/NIPR Attachments
Warehouse?
NA ___
5. Are
you
a
Citizen
of the
United
States?
If No,
you
must
provide proof
of
eligibility
to work
YES ___ NO ___
in
the United States.
Signature: ________________________________________
Date: _______________________