Form DOIVIABRK0715 "Viatical Settlement Broker Individual License Application (Not Life Licensed)" - Nebraska

What Is Form DOIVIABRK0715?

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:

  • Released on May 1, 2016;
  • The latest edition provided by the Nebraska Department of Insurance;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form DOIVIABRK0715 by clicking the link below or browse more documents and templates provided by the Nebraska Department of Insurance.

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Download Form DOIVIABRK0715 "Viatical Settlement Broker Individual License Application (Not Life Licensed)" - Nebraska

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REQUIREMENTS AND PROCEDURE FOR OBTAINING A
VIATICAL SETTLEMENT BROKERS LICENSE
WHO ARE NOT LIFE LICENSED
QUALIFICATIONS
1.
Applicant shall be at least 18 years of age.
2.
Demonstrated evidence of financial responsibility.
PROCEDURE
Submit the “Viatical Settlement Broker Individual License Application” (Form DOIVIABRK) and
bond or other evidence of financial responsibility to the Licensing Division at the address listed
below. Also include a check in payment of the license fee. Refer to the Schedule of Fees listed
below.
PRE-LICENSING EDUCATION REQUIREMENTS
There are no pre-licensing requirements for this license type.
EXAMINATION PROCEDURE
Information regarding the insurance examination procedure is available at
www.prometric.com
or
from the Department of Insurance Licensing Division upon request.
LICENSE FEES
Initial License Fee……………………………………………………….…… $40.00
Renewal Fee …………………………………………………….………..….. $40.00
(Please make checks payable to the Nebraska Department of Insurance)
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 which his/her age is divisible by two.
DOI-INS_VSL
Rev 5/16
REQUIREMENTS AND PROCEDURE FOR OBTAINING A
VIATICAL SETTLEMENT BROKERS LICENSE
WHO ARE NOT LIFE LICENSED
QUALIFICATIONS
1.
Applicant shall be at least 18 years of age.
2.
Demonstrated evidence of financial responsibility.
PROCEDURE
Submit the “Viatical Settlement Broker Individual License Application” (Form DOIVIABRK) and
bond or other evidence of financial responsibility to the Licensing Division at the address listed
below. Also include a check in payment of the license fee. Refer to the Schedule of Fees listed
below.
PRE-LICENSING EDUCATION REQUIREMENTS
There are no pre-licensing requirements for this license type.
EXAMINATION PROCEDURE
Information regarding the insurance examination procedure is available at
www.prometric.com
or
from the Department of Insurance Licensing Division upon request.
LICENSE FEES
Initial License Fee……………………………………………………….…… $40.00
Renewal Fee …………………………………………………….………..….. $40.00
(Please make checks payable to the Nebraska Department of Insurance)
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 which his/her age is divisible by two.
DOI-INS_VSL
Rev 5/16
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 WHO ARE NOT LIFE LICENSED ONLY
A resident viatical settlement broker is required to complete fifteen (15) hours of continuing
education activities; Three (3) of the fifteen hours must be in the area of insurance related
ethics.
Detailed information regarding the two-year continuing education requirements are available
from the Department upon request.
CHANGE OF ADDRESS
Any person licensed under the Viatical Settlements 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.
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
Licensing Division: (402) 471-4913
DOI-INS_VSL
Rev 5/16
For Department Use Only
STATE OF NEBRASKA
Amt. Rec’d __________
DEPARTMENT OF INSURANCE
PO Box 82089
Date Rec’d __________
Lincoln, NE 68501
Tracking No. __________
www.doi.nebraska.gov
VIATICAL SETTLEMENT BROKER
INDIVIDUAL LICENSE APPLICATION
( For Producers Who Are NOT Currently Life Licensed )
(Please Print or Type)
1) Soc. Security Number
2) National Producer Number (NPN)
-
-
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 Entity Name
15) Business Address
16) City
17) State
18) Zip Code
19) Bus Phone
20) Bus Fax
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?
You
may
exclude
the
following
misdemeanor
convictions
or
pending misdemeanor
charges:
traffic
citations,
driving
under
the
influence
YES
NO
(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
YES
NO
a felony?
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?
YES
NO
NA
If so, was consent granted? (Attach copy of 1033 consent approved by home state.)
1c. Have you ever been convicted of a military offense, had a judgment withheld or deferred, or are you currently charged with
YES
NO
committing a 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 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.
DOIVIABRK0715
Page 1 of 5
Applicant’s Name: _______________________________________________
Background Questions (Continued)
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 producer,
or have you ever been subject to a bankruptcy proceeding? Do not include personal bankruptcies, unless they involve funds held
YES
NO
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
YES
NO
allegations of fraud, misappropriation or conversion of funds, misrepresentation or breach of fiduciary duty?
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
_________________________________________________________
Full Legal Name (Printed or Typed)
Additional Requirements
The following Information should be included when submitting your application;
1. A check in the amount of $40.00
2. Evidence of financial responsibility in the amount of $250,000 through either a surety bond or a deposit of cash, certificates of deposit, or securities.
3. Provide a copy of an anti-fraud plan meeting the requirements of Neb.Rev.Stat. §44-1112(7).
4. For Non-Resident License Applications and unless otherwise noted in the State Matrix of Business Rules, a state will rely on an electronic
verification of an Applicant’s resident license through the NAIC’s State Producer Licensing Database in lieu of requiring an original Letter of
Certification from the resident state.
Application should be mailed to:
STATE OF NEBRASKA
DEPARTMENT OF INSURANCE
PO Box 82089
Lincoln, NE 68501
(402) 471-4913
DOIVIABRK0715
Page 2 of 5
BOND OR OTHER EVIDENCE OF FINANCIAL RESPONSIBILITY
Each application must be accompanied by either (1) a surety bond executed and issued by an insurer
authorized to issue surety bonds in Nebraska or evidence of the existence of a deposit of cash, certificates
of deposit, or securities or any combination thereof in the amount of $250,000, or (2) proof that financial
instruments in accordance with these requirements have been filed with one or more states where the
applicant is licensed as a viatical settlement broker.
Any surety bond issued pursuant to this clause must be in favor of Nebraska and must specifically
authorize recovery by the director of the Department of Insurance on behalf of any person in Nebraska
who sustained damages as the result of erroneous acts, failure to act, conviction of fraud, or conviction of
unfair practices by the viatical settlement broker.
Please mark the applicable option:
SURETY BOND
1. A surety bond in the amount of $250,000. The surety bond must be executed on the form
included in this application. Attach the original copy of the properly executed bond and
acknowledgment of principal/surety and power of attorney.
OTHER EVIDENCE OF FINANCIAL RESPONSIBILITY
2. In lieu of a surety bond, the applicant may deposit with the director, or with banks in Nebraska
that the applicant designates, cash, certificates of deposit, or securities or any combination
thereof to an aggregate amount, based upon principal amount or market value, whichever is
lower, of not less than the amount of $250,000. The cash, certificates of deposit, or securities
must be deposited and held to secure the same obligations as the security device. The depositor
shall receive all interest and dividends. The depositor may, with the approval of the director,
substitute other securities for those deposited.
We will accept proof of cash, certificates of deposit or securities that have been filed in another state
where the applicant is licensed as a viatical settlement broker.
DOIVIABRK0715
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