"Financial Disclosure Statement Form" - Nebraska

Financial Disclosure Statement Form is a legal document that was released by the Nebraska Department of Insurance - a government authority operating within Nebraska.

Form Details:

  • Released on February 1, 2007;
  • The latest edition currently provided by the Nebraska Department of Insurance;
  • Ready to use and print;
  • Easy to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

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

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Download "Financial Disclosure Statement Form" - Nebraska

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FINANCIAL DISCLOSURE STATEMENT
Title Insurance Agent and/or Agency
__________________________________________________
________________________
Name of Agent
Nebraska Agent Number
__________________________________________________
________________________
Name of Agency, Company or Firm
Nebraska Company Number
____________________________________________________________________________
Address
City
State
Zip Code
List the names and addresses of all persons that have a financial interest in the title insurance
agent and/or agency listed above, and who you know, or have reason to believe are producers or
associates of producers of title insurance business. See Instructions.
______________________________________________ ________________________
Name
Nature of Financial Interest
______________________________________________ ________________________
Address
City
State
Zip Code Percent of Interest Held
_________________________
Date Acquired or Sold
______________________________________________ ________________________
Name
Nature of Financial Interest
______________________________________________ ________________________
Address
City
State
Zip Code Percent of Interest Held
_________________________
Date Acquired or Sold
______________________________________________ ________________________
Name
Nature of Financial Interest
______________________________________________ ________________________
Address
City
State
Zip Code Percent of Interest Held
_________________________
Date Acquired or Sold
______________________________________________ _________________________
Signature of Agent or Agency’s Designated Agent
Date
Submit form to:
Nebraska Department of Insurance
Attention: Licensing Division
941 O Street, Suite 400
Lincoln, NE 68508
02/07
FINANCIAL DISCLOSURE STATEMENT
Title Insurance Agent and/or Agency
__________________________________________________
________________________
Name of Agent
Nebraska Agent Number
__________________________________________________
________________________
Name of Agency, Company or Firm
Nebraska Company Number
____________________________________________________________________________
Address
City
State
Zip Code
List the names and addresses of all persons that have a financial interest in the title insurance
agent and/or agency listed above, and who you know, or have reason to believe are producers or
associates of producers of title insurance business. See Instructions.
______________________________________________ ________________________
Name
Nature of Financial Interest
______________________________________________ ________________________
Address
City
State
Zip Code Percent of Interest Held
_________________________
Date Acquired or Sold
______________________________________________ ________________________
Name
Nature of Financial Interest
______________________________________________ ________________________
Address
City
State
Zip Code Percent of Interest Held
_________________________
Date Acquired or Sold
______________________________________________ ________________________
Name
Nature of Financial Interest
______________________________________________ ________________________
Address
City
State
Zip Code Percent of Interest Held
_________________________
Date Acquired or Sold
______________________________________________ _________________________
Signature of Agent or Agency’s Designated Agent
Date
Submit form to:
Nebraska Department of Insurance
Attention: Licensing Division
941 O Street, Suite 400
Lincoln, NE 68508
02/07
INSTRUCTIONS
Neb. Rev. Stat. § 44-19,112 provides, “The director shall require each title insurance agent to
file, on forms prescribed by the director, reports setting forth the names and addresses of those
persons, if any, that have a financial interest in the title insurance agent and who the title
insurance agent knows or has reason to believe are producers of title insurance business or
associates of producers of title insurance business.”
Person is defined as any natural person, partnership, association, cooperative, corporation, trust,
or other legal entity. See Neb. Rev. Stat. § 44-19,108(9).
Producer of title insurance business is defined as any person, including an officer, director, or
owner of five percent or more of the equity or capital of any person, engaged in this state in the
trade, business, occupation, or profession of:
a) Buying or selling interests in real property;
b) Making loans secured by interests in real property; or
c) Acting as broker, agent, representative, or attorney of a person who buys or sells any
interest in real property or who lends or borrows money with the interest as security.
See Neb. Rev. Stat. § 44-19,108(10).
Financial interest is defined as a direct or indirect interest, legal or beneficial, when the holder
is or will be entitled to five percent or more of the net profits or net worth of the entity in which
the interest is held. See Neb. Rev. Stat. § 44-19,108(8).
1.
All title insurance agents and agencies subject to disclosure of financial interests under
Neb. Rev. Stat. § 44-19,112 must have a Financial Disclosure Statement on file with the
Nebraska Department of Insurance.
2.
Annual filing of the Financial Disclosure Statement is NOT required.
3.
A new Financial Disclosure Statement must be filed each time there is a change in such
financial interest.
4.
Failure to maintain a current Financial Disclosure Statement on file with the Department
is a violation of the Nebraska Title Insurance Agent Act, and may result in a fine and/or
suspension or revocation of the agent and agency insurance licenses.
02/07
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