Form DOI-1217 "Insurance Consultant License Application" - Nebraska

What Is Form DOI-1217?

This is a legal form that was released by the Nebraska Department of Insurance - a government authority operating within Nebraska. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

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Download a fillable version of Form DOI-1217 by clicking the link below or browse more documents and templates provided by the Nebraska Department of Insurance.

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Download Form DOI-1217 "Insurance Consultant License Application" - Nebraska

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REQUIREMENTS AND PROCEDURE FOR OBTAINING AN
INSURANCE CONSULTANT’S LICENSE
RESIDENT AND NONRESIDENT
QUALIFICATIONS
1.
Applicant shall be at least 18 years of age.
2.
Applicant shall be competent, trustworthy, financially responsible, and of good personal and
business reputation.
3.
Applicant shall have been licensed as an agent, broker, or consultant in this state or another state
for the three years immediately preceding the date of application or have successfully completed
a specific program of study, which has a broad national or regional recognition as determined by
the Director.
4.
Applicant shall pass the appropriate qualifying examinations.
Nonresident Applicants – The Director may exempt from examination any nonresident applicant whose
resident state or province has examination standards substantially the same as those of Nebraska.
PROCEDURE
You can start the application process online at
www.nipr.com
and pay the license fee with a
credit card, or you can complete a
and mail
paper application for the Insurance Consultant’s License,
it with a check made payable to the Nebraska Department of Insurance.
Applicant should also include:
• License fee (Refer to the License Fees listed below)
• Any additional documentation regarding “Yes” answers to the background
questions, including both court documents and an explanation of the event.
EXAMINATION PROCEDURE
Applicants should register and pass the written insurance examination for the appropriate lines of
authority. Visit
www.prometric.com
to register for your insurance exam.
Additional information regarding exam rules and regulations can be found at the following
Neb. Rev. Stat. § 44-2619, 44-2622, 44-2625.
Study Materials
You may use the material of your choosing to study for the license exam. Many different providers offer
exam prep courses and because of the number and array of methods the department does not review,
approve or recommend providers.
Nebraska statutes are referenced on the topic outline additionally and are available to review online or
at any public library.
Exam Content Outlines
Each license consists of an outline broken down into each topic and the percentage of questions covered
for each topic. The outlines can be viewed at
www.prometric.com/en-us/clients/insurance/Pages/ne-
content-outlines.aspx
DOI-INS_CON
Rev 07/2018
REQUIREMENTS AND PROCEDURE FOR OBTAINING AN
INSURANCE CONSULTANT’S LICENSE
RESIDENT AND NONRESIDENT
QUALIFICATIONS
1.
Applicant shall be at least 18 years of age.
2.
Applicant shall be competent, trustworthy, financially responsible, and of good personal and
business reputation.
3.
Applicant shall have been licensed as an agent, broker, or consultant in this state or another state
for the three years immediately preceding the date of application or have successfully completed
a specific program of study, which has a broad national or regional recognition as determined by
the Director.
4.
Applicant shall pass the appropriate qualifying examinations.
Nonresident Applicants – The Director may exempt from examination any nonresident applicant whose
resident state or province has examination standards substantially the same as those of Nebraska.
PROCEDURE
You can start the application process online at
www.nipr.com
and pay the license fee with a
credit card, or you can complete a
and mail
paper application for the Insurance Consultant’s License,
it with a check made payable to the Nebraska Department of Insurance.
Applicant should also include:
• License fee (Refer to the License Fees listed below)
• Any additional documentation regarding “Yes” answers to the background
questions, including both court documents and an explanation of the event.
EXAMINATION PROCEDURE
Applicants should register and pass the written insurance examination for the appropriate lines of
authority. Visit
www.prometric.com
to register for your insurance exam.
Additional information regarding exam rules and regulations can be found at the following
Neb. Rev. Stat. § 44-2619, 44-2622, 44-2625.
Study Materials
You may use the material of your choosing to study for the license exam. Many different providers offer
exam prep courses and because of the number and array of methods the department does not review,
approve or recommend providers.
Nebraska statutes are referenced on the topic outline additionally and are available to review online or
at any public library.
Exam Content Outlines
Each license consists of an outline broken down into each topic and the percentage of questions covered
for each topic. The outlines can be viewed at
www.prometric.com/en-us/clients/insurance/Pages/ne-
content-outlines.aspx
DOI-INS_CON
Rev 07/2018
Testing Centers Regulations, Testing Process and Sample Score Report can be reviewed in the Prometric
Licensing Information Handbook.
LICENSE FEES
Initial License Fee……………………………………………………….…… $50.00
Renewal Fee …………………………………………………….………..….. $50.00
Late Re-issuance Fee (within 30 days after expiration) ….….. $90.00
Reinstatement fee (after 30 days and up to 12 months) .... $90.00
PRINTING LICENSES
The Nebraska Department of Insurance Licensing Division no longer mails out a hard copy of new or
renewed licenses. A copy of your license can be downloaded or printed by going to:
www.statebasedsystems.com/LicensePrint.htm.
LICENSE RENEWAL
Initial individual licenses are issued to expire the last day of the month in the licensee’s birth month in
the first year after issuance in which his/her age is divisible by two.
Therefore, individuals born in even numbered years renew their license on their birthday in the
even numbered years and individuals born in odd numbered years renew their license on their birthday
in the odd numbered years.
CONTINUING EDUCATION REQUIREMENTS (2 YEARS)
APPLIES TO RESIDENT LICENSEES ONLY
A resident consultant is required to complete twenty-four hours of continuing education activities;
Three (3) of the 24 hours must be in the area of insurance related ethics.
The 24 hours of continuing education is not in addition to the requirement for the Nebraska Producer
Insurance license.
CHANGE OF ADDRESS
Any person, corporation or partnership licensed under the Insurance Consultant’s Act shall notify the
Department within thirty (30) days of any change of residential or business address. Form DOI-9110
must be submitted to report a change of address.
For more information regarding the rules and regulation pertaining to the Insurance Consultant License
please see Neb. Rev. Stat. §
44-2606 to
44-2635.
Reasonable accommodations for disabled persons available
upon request at (402) 471-2201. TDD users 800-833-7352 for relay to (402) 471-2201
NEBRASKA DEPARTMENT OF INSURANCE
P.O. BOX 82089
LINCOLN, NE 68501-2089
E-mail: DOI.Licensing@Nebraska.gov
Licensing Division: (402) 471-4913
Fax: (402) 471-6559
DOI-INS_CON
Rev 07/2018
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 CONSULTANT LICENSE
APPLICATION
REGISTRATION FORM
Select License Type
___ Resident Life and Health Consultant
___ Non-Resident Life and Health Consultant
___ Resident Property and Casualty Consultant
___ Non-Resident Property and Casualty Consultant
(Please Print or Type)
1) Soc. Security Number
2) National Producer Number (NPN)
-
-
3) Agency Name (If doing Insurance Consultant business through agency, please complete a Corporate Insurance Consultant Application)
3) Last Name
4) First Name
5) Middle Name
6) Date of Birth
___/___/_____
7) Residence/Home Address
8) City
9)State
10) Zip Code
11) Home Phone Number
12) Email Address
13) Are you a citizen of the United States?
Yes
No – Which country are you a citizen? __________________________
(If answer is No, and this is an application for a Resident License, you must supply proof of eligibility to work in the U.S.)
14) Business Name
15) Business Address
16) City
17) State
18) Zip Code
20) Bus Email Address
19) Bus Phone
Previous Work History (Last 5 Years)
Employer Name
From
To
License History
1. Are you now or have you ever been licensed in any other state(s) to transact any form of insurance or consulting?
YES
NO
If YES, please give the state(s) and license date(s).
2. List the names and addresses of all insurance companies or consulting firms with which you have been associated. Give date(s) and state(s) and indicate whether
officer, employee, or producer. (If additional space is needed, please use a separate sheet and include it with your application)
3. Have you ever been terminated or discharged by an insurance company or consulting firm? If YES, please provide an
YES
NO
explanation.
4. Have authorities of any state called you before them for any alleged violations of insurance or consulting laws? If YES,
YES
NO
please provide an explanation.
5.
Has any state ever refused, revoked, suspended, or terminated your insurance license(s) or consultant license(s)?
YES
NO
If YES, please provide an explanation.
DOI_INSCON1217
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Education & Insurance Designations
Please include any education history or designations that you hold that are related to the insurance industry.
Background Questions
1a. Have you ever been convicted of a misdemeanor, had a judgment withheld or deferred, or are you 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),
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
a juvenile
court)
1b. Have you ever been convicted of a felony, had a judgment withheld or deferred, or are you 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
YES
NO
NA
business of insurance in your home state as required by 18 USC 1033?
If so, was consent granted? (Attach copy of 1033 consent approved by home state.)
YES
NO
NA
1c. Have you ever been convicted of a military offense, had a judgment withheld or deferred, or are you currently charged with
committing a military offense?
YES
NO
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 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 ever been named or involved as a party in an administrative proceeding, including 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, 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.
NOTE: If you answered yes to question number 2, 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. Has any demand been made or judgment rendered against you or any business in which you are or were an owner, partner,
officer or director, or member or manager of a limited liability company, for overdue monies by an insurer, insured or
YES
NO
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.
If you answer yes, submit a statement summarizing the details of the indebtedness and arrangements for repayment,
and/or type and location of bankruptcy.
4. Have you 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): ________________________________________________________________
5. Are you currently a party to, or have you ever been found liable in, any lawsuit, arbitrations or mediation proceeding
involving allegations of fraud, misappropriation or conversion of funds, misrepresentation or breach of fiduciary duty?
YES
NO
6. Do you have a child support obligation in arrearage?
YES
NO
DOI_INSCON1217
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Consultant Fees
Please initial for
The applicant is aware that it is unlawful for any consultant, agency, or sales organization with which he or she is connected, to receive any part
acknowledgment
of any commission of compensation paid by an insurer or producer of an insurer in connection with the sale or writing of any insurance which
is within the subject matter of any consulting service for which such consultant has contracted to receive a fee?
Applicant’s Certification and Attestation
The Applicant must read the following very carefully:
1. I hereby certify that, under penalty of perjury, all of the information submitted in this application and attachments is true and complete. I am aware that
submitting false information or omitting pertinent or material information in connection with this application is grounds for license revocation or denial of
the license and may subject me to civil or criminal penalties.
2. Unless provided otherwise by law or regulation of the jurisdiction , I hereby designate the Commissioner, Director or Superintendent of Insurance, or
other appropriate party in each jurisdiction for which this application is made to be my agent for service of process regarding all insurance matters in the
respective jurisdiction and agree that service upon the Commissioner, Director or Superintendent of Insurance, or other appropriate party of that jurisdiction
is of the same legal force and validity as personal service upon myself.
3. I further certify that I grant permission to the Commissioner, Director or Superintendent of Insurance, or other appropriate party in each jurisdiction for
which this application is made to verify information with any federal, state or local government agency, current or former employer, or insurance company.
4. I further certify that, under penalty of perjury, a) I have no child-support obligation, b) I have a child-support obligation and I am currently in compliance
with that obligation, or c) I have identified my child support obligation arrearage on this application.
5. I authorize the jurisdictions to which this application is made to give any information concerning me, as permitted by law, to any federal, state or
municipal agency, or any other organization and I release the jurisdictions and any person acting on their behalf from any and all liability of whatever
nature by reason of furnishing such information.
6. I acknowledge that I understand and will comply with the insurance laws and regulations of the jurisdictions to which I am applying for licensure.
7. For Non-Resident License Applications, I certify that I am licensed and in good standing in my home state/resident state for the lines of authority requested
from the non-resident state.
8. I hereby certify that upon request, I will furnish the jurisdiction(s) to which I am applying, certified copies of any documents attached to this application
or requested by the jurisdiction(s).
_________________________________________________________________
__________________________________________________________
Original Applicant Signature
Month/Day/Year
License Qualifications
Every individual applicant for a license under sections 44-2606 to 44-2635 shall have attained the age of majority, shall be competent,
trustworthy, financially responsible, and of good personal and business reputation, and shall have been licensed as an agent, broker, or
consultant in this state or another state for the three years immediately preceding the date of application or have successfully completed
a specific program of study which has a broad national or regional recognition as determined by the director.
No person shall, in or on advertisements, cards, signs, circulars, letterheads, or elsewhere or in any other manner by which public
announcements are made, use the title insurance consultant, public adjustor, or any similar title or any title, word, combination of
words, or abbreviation indicating that he or she gives or is engaged in the business of offering to the public any advice, counsel,
opinion, or service with respect to insurable risks, concerning the benefits, coverages, or provisions under any policy of insurance that
could be issued in this state, or involving the advantages or disadvantages of any such policy of insurance, unless such person holds a
license as an insurance consultant under sections 44-2606 to 44-2635.
Any corporation, partnership, or limited liability company engaged in the business of insurance consulting may become licensed as an
insurance consultant. No license shall be granted to a corporation, partnership, or limited liability company unless the corporation,
partnership, or limited liability company designates a licensed consultant who shall have full responsibility for all insurance consulting
transactions of the corporation, partnership, or limited liability company within the state. Such designated consultant shall be an officer
of the corporation or a member of the partnership or limited liability company and shall have a substantial interest in or be an active
participant in the management of the corporation, partnership, or limited liability company. If a corporation, partnership, or limited
liability company has more than one office, it shall designate a consultant for each office. In the event a designated consultant of a
licensed corporation, partnership, or limited liability company shall either leave the corporation, partnership, or limited liability
company or have his or her license revoked, the corporation, partnership, or limited liability company shall have sixty days after such
revocation in which to designate another qualified licensed consultant, or have its license revoked. Any individual associated with a
licensed corporation, partnership, or limited liability company who acts as an insurance consultant shall be a licensed consultant.
NEBRASKA DEPARTMENT OF INSURANCE
P.O. BOX 82089
LINCOLN, NE 68501-2089
E-mail: DOI.Licensing@Nebraska.gov
Licensing Division: (402) 471-4913
DOI_INSCON1217
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