Form 8301-BE "Naic Business Entity Insurance License Application" - Kentucky

What Is Form 8301-BE?

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

Form Details:

  • Released on July 1, 2014;
  • The latest edition provided by the Kentucky 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 8301-BE by clicking the link below or browse more documents and templates provided by the Kentucky Department of Insurance.

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Download Form 8301-BE "Naic Business Entity Insurance License Application" - Kentucky

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For Office Use Only
Check appropriate box for
Amt. Rec’d
_____________
license requested.
Resident License
Date Rec’d
_____________
o
Reinstate __Yes __ No
. ____________
Tracking No
Non-Resident License
Identify Home State:
____________
Cashier:
COMMONWEALTH OF KENTUCKY
_________________
DEPARTMENT OF INSURANCE
Amt. Rec’d
_____________
Identify Home State License
P. O. Box 517
_________
#:
Date Rec’d
_____________
Frankfort, Kentucky 40602-0517
o
New
____________
email: DOI.AgentLicensingMail@ky.gov
Tracking No.
o
Add
http://insurance.ky.gov
o
Cashier:
_____________
Reinstate
502-564-6004
(PLEASE PRINT OR TYPE)
NAIC BUSINESS ENTITY INSURANCE LICENSE APPLICATION
emographic Information
D
Business Entity Name
Incorporation/Formation Date
FEIN
1
2
3
(month) ___(day) ___(year) _____
-
If assigned, National Producer Number (NP#)
If applicable, NASD Firm Central Registration Depository (CRD) Number
4
5
List any other assumed, fictitious, alias or trade names under which you are doing
State of Domicile
Country of Domicile
7
8
6
business or intend to do business.
Is the business entity affiliated with a financial institution/bank?
Yes
No
9
13
10
11
12
14
Business Address
City
State
ZIP
Foreign Country
1
1
15
Phone Number (include
16
Fax Number
17
Business Web Site Address
Business E-Mail Address
18
extension)
(
)
-
(
)
-
24
19
20
21
22
23
Mailing Address
P.O. Box
City
State
ZIP
Foreign Country
8
Designated/Responsible Licensed Producer
Identify at least one Designated/Responsible Licensed Producer: (See Matrix of State Requirements at www.licenseregistry.com for jurisdictions that require the
25
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
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:
26
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 ____
Page 1 of 3
For Office Use Only
Check appropriate box for
Amt. Rec’d
_____________
license requested.
Resident License
Date Rec’d
_____________
o
Reinstate __Yes __ No
. ____________
Tracking No
Non-Resident License
Identify Home State:
____________
Cashier:
COMMONWEALTH OF KENTUCKY
_________________
DEPARTMENT OF INSURANCE
Amt. Rec’d
_____________
Identify Home State License
P. O. Box 517
_________
#:
Date Rec’d
_____________
Frankfort, Kentucky 40602-0517
o
New
____________
email: DOI.AgentLicensingMail@ky.gov
Tracking No.
o
Add
http://insurance.ky.gov
o
Cashier:
_____________
Reinstate
502-564-6004
(PLEASE PRINT OR TYPE)
NAIC BUSINESS ENTITY INSURANCE LICENSE APPLICATION
emographic Information
D
Business Entity Name
Incorporation/Formation Date
FEIN
1
2
3
(month) ___(day) ___(year) _____
-
If assigned, National Producer Number (NP#)
If applicable, NASD Firm Central Registration Depository (CRD) Number
4
5
List any other assumed, fictitious, alias or trade names under which you are doing
State of Domicile
Country of Domicile
7
8
6
business or intend to do business.
Is the business entity affiliated with a financial institution/bank?
Yes
No
9
13
10
11
12
14
Business Address
City
State
ZIP
Foreign Country
1
1
15
Phone Number (include
16
Fax Number
17
Business Web Site Address
Business E-Mail Address
18
extension)
(
)
-
(
)
-
24
19
20
21
22
23
Mailing Address
P.O. Box
City
State
ZIP
Foreign Country
8
Designated/Responsible Licensed Producer
Identify at least one Designated/Responsible Licensed Producer: (See Matrix of State Requirements at www.licenseregistry.com for jurisdictions that require the
25
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
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:
26
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 ____
Page 1 of 3
DOI
Form 8301 - BE;
Rev. 07/2014
Uniform Application for
Business Entity Insurance License/Registration
Applicant Name____________________________________________________
Background Questions
29
Please read the following very carefully and answer every question. All written statements submitted by the Applicant must include an
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
Yes ___ No___
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?
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
Yes ___ No ___
director of the business entity or member or manager of a limited liability company currently charged with committing 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 business
N/A___Yes___No___
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.)
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
Yes ___ No ___
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,
Yes ___ No___
or member or manager if 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.
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, director of the business entity, or member or manager of a limited liability company,
Yes ___ No___
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?
If you answer yes, identify the jurisdiction(s): _______________________________________
DOI
Form 8301 - BE;
Rev. 07/2014
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,
Yes ___ No___
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?
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 demonstrate 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
Yes ___ No___
company ever had an insurance agency contract or any other business relationship with an insurance company terminated for any alleged
misconduct?
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
NAIC/NIPR Attachments Warehouse?
Yes ___ No ___
If you answer yes, will you be associating (linking) previously filed documents from the NAIC/NIPR Attachments Warehouse to this
application?
Note: If you have previously submitted
Yes ___ No ___
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.
Page 2 of 3
DOI
Form 8301 - BE;
Rev. 07/2014
Uniform Application for
Business Entity Insurance License/Registration
Applicant Name ______________________________________________
RESIDENT
NON-RESIDENT
AGENT MAJOR LINES
ADJUSTERS
Independent Adjuster
Public Adjuster
Casualty
Health
for Prop. & Casualty
for Prop & Casualty
Independent Adjuster
Life
Property
for Workers' Comp
Variable Life and
Independent Adjuster
Variable Annuity
Personal Lines
for Crop
AGENT LIMITED LINES
OTHER LICENSES
Crop
Travel
Surplus Lines Broker
Administrator (TPA)
Self-Service
Life Settlement
Credit
Storage Space
Provider
Life Settlement Broker
Reinsurance
Reinsurance
Rental Vehicle Agent
Intermediary Broker
Intermediary Manager
Managing General
CONSULTANT LICENSES
Agent (MGA)
Life & Health
Property & Casualty
Consultant
Consultant
Applicant’s Certification and Attestation
30
On behalf of the business entity or limited liability company, the undersigned owner, partner, officer or director of the business entity, or member or manager of a limited
liability company, hereby certifies, under penalty of perjury, that:
1.
All of the information submitted in this application and attachments is true and complete and I am aware that submitting false information or omitting pertinent or material
information in connection with this application is grounds for license or registration revocation and may subject me and the business entity or limited liability company to
civil or criminal penalties.
2.
Unless provided otherwise by law or regulation of the jurisdiction , the business entity or limited liability company hereby designates the Commissioner, Director or
Superintendent of Insurance, or an appropriate representative in each jurisdiction for which this application is made to be its agent for service of process regarding all
insurance matters in the respective jurisdiction and agree that service upon the Commissioner or Director of that jurisdiction is of the same legal force and validity as
personal service upon the business entity.
3.
The business entity or limited liability company grants permission to the Commissioner or Director of Insurance in each jurisdiction for which this application is made to
verify any information supplied with any federal, state or local government agency, current or former employer or insurance company.
4.
Every owner, partner, officer or director of the business entity, or member or manager of a limited liability company, either a) does not have a current child-support
obligation, or b) has a child-support obligation and is currently in compliance with that obligation.
5.
I authorize the jurisdictions to which this application is made to give any information they may have 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 comply with the insurance laws and regulations of the jurisdictions to which I am applying for licensure/registration.
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).
I certify that the Designated Responsible Licensed Producer(s) named on this application understands that he/she is responsible for the business entity’s compliance with
9.
the insurance laws, rules and regulation of the State.
Must be signed by an officer, director, or partner of the business entity, or member or manager if a limited liability company:
____________________________________________
Month/Day/Year
____________________________________________
Signature
_________________________________________________
____________________________________________________
Typed or Printed Name
Address
_________________________________________________
___________________________________________________
Title
City
State
Zip
Attachments
31
The following attachments must accompany the application otherwise the application may be returned unprocessed or considered deficient.
DOI
Form 8301 - BE;
Rev. 07/2014
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
1.
resident license through the NAIC’s State Producer Database in lieu of requiring an original Letter of Certification from the resident state.
2.
Any jurisdiction specific attachments listed in the State Matrix of Business Rules (www.nipr.com).
Page 3 of 3