"Application for Written Consent to Engage in the Business of Insurance Pursuant to 18 U.s.c. 1033 and 1034" - Kentucky

Application for Written Consent to Engage in the Business of Insurance Pursuant to 18 U.s.c. 1033 and 1034 is a legal document that was released by the Kentucky Department of Insurance - a government authority operating within Kentucky.

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KENTUCKY DEPARTMENT OF INSURANCE
APPLICATION
FOR WRITTEN CONSENT
TO ENGAGE IN THE
BUSINESS OF INSURANCE
PURSUANT TO 18 U.S.C. §§ 1033 AND 1034
Notice to Applicant: 18 U.S.C. § 1033 prohibits certain activities by or affecting persons engaged, or
proposing to become engaged, in the business of insurance:
(e)(1)(A)
Any individual who has been convicted of any criminal felony involving dishonesty or a
breach of trust, or who has been convicted of an offense under this section, and who willfully
engages in the business of insurance whose activities affect interstate commerce or
participates in such business, shall be fined as provided in this title or imprisoned not more
than 5 years, or both.
(B)
Any individual who is engaged in the business of insurance whose activities affect interstate
commerce and who willfully permits the participation described in subparagraph (A) shall be
fined as provided in this title or imprisoned not more than 5 years, or both.
(e)(2)
A person described in paragraph (1)(A) may engage in the business of insurance or
participate in such business if such person has the written consent of any regulatory official
authorized to regulate the insurer, which consent specifically refers to this section.
This Application will be reviewed by the Commissioner of Insurance to determine whether the Applicant
should be given written consent to engage in the business of insurance or participate in the business
pursuant to 18 U.S.C. § 1033(e)(2).
You must answer every question on the Application. If a question does not apply, indicate N/A in the space
provided for the answer. Your answers are not limited to the space provided on the Application. Attach
additional pages as needed. The Department of Insurance will not process incomplete Applications. This
Application must be provided to the Department of Insurance within thirty (30) days of your receipt of this
Application form. Additional information may be requested. After determining the Application is complete, if
necessary, the Department will notify you of a date and time for a meeting with the Department’s 1033
Advisory Committee during which you may orally present your reasons why you believe the Commissioner
should grant you consent.
One original and five (5) duplicate copies of this application form should be mailed to:
Kentucky Department of Insurance
Office of General Counsel
18 U.S.C. § 1033 Advisory Committee
P. O. Box 517
Frankfort, KY 40602
1
KENTUCKY DEPARTMENT OF INSURANCE
APPLICATION
FOR WRITTEN CONSENT
TO ENGAGE IN THE
BUSINESS OF INSURANCE
PURSUANT TO 18 U.S.C. §§ 1033 AND 1034
Notice to Applicant: 18 U.S.C. § 1033 prohibits certain activities by or affecting persons engaged, or
proposing to become engaged, in the business of insurance:
(e)(1)(A)
Any individual who has been convicted of any criminal felony involving dishonesty or a
breach of trust, or who has been convicted of an offense under this section, and who willfully
engages in the business of insurance whose activities affect interstate commerce or
participates in such business, shall be fined as provided in this title or imprisoned not more
than 5 years, or both.
(B)
Any individual who is engaged in the business of insurance whose activities affect interstate
commerce and who willfully permits the participation described in subparagraph (A) shall be
fined as provided in this title or imprisoned not more than 5 years, or both.
(e)(2)
A person described in paragraph (1)(A) may engage in the business of insurance or
participate in such business if such person has the written consent of any regulatory official
authorized to regulate the insurer, which consent specifically refers to this section.
This Application will be reviewed by the Commissioner of Insurance to determine whether the Applicant
should be given written consent to engage in the business of insurance or participate in the business
pursuant to 18 U.S.C. § 1033(e)(2).
You must answer every question on the Application. If a question does not apply, indicate N/A in the space
provided for the answer. Your answers are not limited to the space provided on the Application. Attach
additional pages as needed. The Department of Insurance will not process incomplete Applications. This
Application must be provided to the Department of Insurance within thirty (30) days of your receipt of this
Application form. Additional information may be requested. After determining the Application is complete, if
necessary, the Department will notify you of a date and time for a meeting with the Department’s 1033
Advisory Committee during which you may orally present your reasons why you believe the Commissioner
should grant you consent.
One original and five (5) duplicate copies of this application form should be mailed to:
Kentucky Department of Insurance
Office of General Counsel
18 U.S.C. § 1033 Advisory Committee
P. O. Box 517
Frankfort, KY 40602
1
PLEASE TYPE
SECTION I – APPLICANT INFORMATION
Full Name of Applicant:
Last Name
First Name
Middle
SS#
Home Address
City
County
State
ZIP
Home Phone
Business Address
City
County
State
ZIP
Business Phone
1.
If you were born in the United States, provide the following:
Place of Birth
City
County
State
ZIP
Date of Birth
2.
If you were not born in the United States, provide the time of first entry and port of entry:
3.
Are you a U.S. Citizen?
yes
no
If no, provide the following:
Citizenship Country
State/Province
Basis of U.S. Residence
Alien Registration Number
4.
If you are a naturalized citizen of the United States, indicate where and how you became
naturalized. The number of the Certificate of Naturalization must be provided, if applicable.
5.
Have you ever used or been known by another name (including maiden name) or used or been
issued another Social Security number?
yes
no
If yes, provide the following (attach additional pages as needed):
Name
Social Security Number
Date of Use
6.
Provide identification of your current, and all former, spouses (attach additional pages as needed):
Spouse’s Last Name
First Name
Middle
Social Security Number
Marital Status
2
7.
Do any of your relatives, by blood or marriage (either current or prior), serve in any capacity with any
entity engaged in the business of insurance?
yes
no
If yes, provide the following (attach additional pages as needed):
Name of Relative
Address
Relationship to Applicant Insurer/Employer
8.
Have you ever been a party, in any capacity, in a civil action, lawsuit, bankruptcy or other
proceeding?
yes
no
If yes, provide details of all civil actions (attach additional pages as needed):
Title of Case
Case Number
Federal
State
Identification of Court
City/State
Date of Action
Description of case and your involvement, including outcome:
SECTION II – EDUCATION
1.
Provide complete details about your education and training, including identification of all schools that
you have attended. Attach additional pages as needed.
Name of High School(s)
Address
Major
Dates Attended
Highest Level Attained
Name of College(s)
Address
Major
Dates Attended
Highest Level Attained
Name of Tech School(s)
Address
Major
Dates Attended
Designation
Post Graduate Schools
Address
Dates Attended
Designation or Programs
3
SECTION III – CHRONOLOGICAL EMPLOYMENT HISTORY AND PROFESSIONAL LICENSES –
CERTIFICATIONS – DESIGNATIONS
1.
List in chronological order each and every place where you have been employed, including any
military service (attach additional pages as needed). Include all instances where you have served as
a paid or non-paid officer or director.
Name of Employer
Address
Title/Job
Employment Dates
Reasons for Leaving
2.
Do you now hold, or have you ever held, a professional license relating to the business of insurance,
including but not limited to, being a producer, agent, broker, solicitor, adjuster, or third party
administrator?
yes
no
If yes, provide the following information about your active or prior insurance professional license(s)
(attach additional pages as needed):
Type of License
Date of Issue
State
Status of License
3.
Have you ever had a consumer complaint, administrative, civil or other legal proceeding (include
pending actions) filed against you regarding your insurance activities?
yes
no
If yes, provide the following (attach additional pages as needed):
Type of Action
Court/Administrative Agency
State
Date of Action
Outcome
4.
If your insurance-related license has ever been suspended, revoked, or administratively sanctioned
(include pending actions) as a result of the legal or administrative action described in this section,
provide the following information (attach additional pages as needed):
Date of Sanction/
Type of License
Fines Paid
Status of Proceeding
Suspension/Revocation
5.
Do you now hold, or have you ever held, any other professional licenses, certifications or
designations not issued by a Department of Insurance?
yes
no
4
If yes, provide the following information about your active or prior professional licenses, certifications
or designations (attach additional pages as needed):
Issued by
Address
City/State
Type of License, certification or designation
Date of Issue
Status of license, certification or designation
6.
Have you ever had a customer, client or consumer complaint, administrative or other legal
proceeding (include pending actions) filed against you regarding your other professional activities?
yes
no
If yes, provide the following (attach additional pages as needed):
Type of Action
Court/Administrative Agency
State
Date of Action
Outcome
7.
If any other professional licenses, certifications or designations have ever been suspended,
revoked, or administratively sanctioned as a result of the legal or administrative action described in
this section (include pending actions), provide the following information (attach additional pages as
needed):
Date of Sanction/Suspension/Revocation
Type of License
Fines Paid
Status of Proceeding
SECTION IV – CRIMINAL HISTORY
1.
Provide a narrative statement describing the circumstances leading to all criminal charge(s) filed
against you: the date of charge(s); place of charge(s); trial court(s); date of disposition; convicted
charge(s); sentence(s); date(s) of incarceration; date(s) of probation/parole; date(s) of release from
probation/parole; restitution ordered; restitution paid; fines/costs ordered; fines/costs paid. Include
details of negotiated plea agreements and pleas of nolo contendere to an information or indictment.
Describe in detail the criminal conviction or convictions which are the subject of this Application.
Attach additional pages if needed.
5