Form INS3245 "Individual Surplus Line Broker License Application Form" - Ohio

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Download this version of Form INS3245 for the current year.

What Is Form INS3245?

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

Form Details:

  • Released on January 1, 2019;
  • The latest edition provided by the Ohio 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 fillable version of Form INS3245 by clicking the link below or browse more documents and templates provided by the Ohio Department of Insurance.

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Download Form INS3245 "Individual Surplus Line Broker License Application Form" - Ohio

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Licensing Division
Ohio Department of Insurance
50 W. Town St., 3rd Fl.
Mike DeWine – Governor
Suite 300
Jillian Froment – Director
Columbus, OH 43215
(614) 644-2665
Individual Surplus Line Broker
Fax # (614) 387-0096
www.insurance.ohio.gov
License Application
(Please Print or Type)
Check appropriate box for license requested:
Resident License
Non-Resident License
Identify Home State:
Identify Home State License #:
Demographic Information
Social Security Number
If assigned, National Producer Number (NPN)
Mobile Phone Number
1
2
3
(
)
4
Last Name
JR./SR. etc
First Name
Middle Name
Date of Birth (M/D/YY)
5
6
7
Residence/Home Address (Physical Street)
City
State
Zip or
Foreign Country
12
8
11
9
10
Home Phone Number
Gender (Check One)
Are you a Citizen of the United States? (Check One)
13
15
16
(
)
Male
Female
Yes
No (if No, of which country are you a citizen? _________________)
(If No, and this is an appplication for a Resident License, you must supply proof of
Individual Applicant Email Address:
14
eligibility to work in the U.S.)
Business Entity’s Name
17
Business Address (Physical Street)
P.O. Box
City
State
Zip or
Foreign Country
18
19
20
23
21
22
Business Phone Number
Business Fax Number
Business E-Mail Address
Business Web Site Address
24
25
26
27
(include extension)
(
)
(
)
Applicant’s Mailing Address
P.O. Box
City
State
Zip or
33
Foreign Country
31
28
29
30
32
a.
List any other assumed, fictitious, alias, maiden or trade names which you have used in the past.
34
b.
List any trade names under which you are currently doing business or intend to do business.
(May be subject to state approval.)
Agency or Business Entity Affiliations
List your Insurance Agency Affiliations: (Complete only if the applicant is to be licensed as an active member of the business entity)
35
FEIN
NPN
Name of Agency
FEIN
NPN
Name of Agency
FEIN
NPN
Name of Agency
Employment History
Account for all time for the past five years. Give all employment experience starting with your current employer working back five years. Include full and part-
36
time work, self-employment, military service, unemployment and full-time education.
From
To
Month
Year
Month
Year
Position Held
Name
City
State
Name
City
State
Name
City
State
Name
City
State
Accredited by the National Association of Insurance Commissioners (NAIC)
INS3245 (Rev. 1/2019)
Page 1 of 4
Licensing Division
Ohio Department of Insurance
50 W. Town St., 3rd Fl.
Mike DeWine – Governor
Suite 300
Jillian Froment – Director
Columbus, OH 43215
(614) 644-2665
Individual Surplus Line Broker
Fax # (614) 387-0096
www.insurance.ohio.gov
License Application
(Please Print or Type)
Check appropriate box for license requested:
Resident License
Non-Resident License
Identify Home State:
Identify Home State License #:
Demographic Information
Social Security Number
If assigned, National Producer Number (NPN)
Mobile Phone Number
1
2
3
(
)
4
Last Name
JR./SR. etc
First Name
Middle Name
Date of Birth (M/D/YY)
5
6
7
Residence/Home Address (Physical Street)
City
State
Zip or
Foreign Country
12
8
11
9
10
Home Phone Number
Gender (Check One)
Are you a Citizen of the United States? (Check One)
13
15
16
(
)
Male
Female
Yes
No (if No, of which country are you a citizen? _________________)
(If No, and this is an appplication for a Resident License, you must supply proof of
Individual Applicant Email Address:
14
eligibility to work in the U.S.)
Business Entity’s Name
17
Business Address (Physical Street)
P.O. Box
City
State
Zip or
Foreign Country
18
19
20
23
21
22
Business Phone Number
Business Fax Number
Business E-Mail Address
Business Web Site Address
24
25
26
27
(include extension)
(
)
(
)
Applicant’s Mailing Address
P.O. Box
City
State
Zip or
33
Foreign Country
31
28
29
30
32
a.
List any other assumed, fictitious, alias, maiden or trade names which you have used in the past.
34
b.
List any trade names under which you are currently doing business or intend to do business.
(May be subject to state approval.)
Agency or Business Entity Affiliations
List your Insurance Agency Affiliations: (Complete only if the applicant is to be licensed as an active member of the business entity)
35
FEIN
NPN
Name of Agency
FEIN
NPN
Name of Agency
FEIN
NPN
Name of Agency
Employment History
Account for all time for the past five years. Give all employment experience starting with your current employer working back five years. Include full and part-
36
time work, self-employment, military service, unemployment and full-time education.
From
To
Month
Year
Month
Year
Position Held
Name
City
State
Name
City
State
Name
City
State
Name
City
State
Accredited by the National Association of Insurance Commissioners (NAIC)
INS3245 (Rev. 1/2019)
Page 1 of 4
Ohio Department of Insurance
Individual Surplus Line Broker License Application
Background Questions
The Applicant must read the following very carefully and answer every question. All written statements submitted by the Applicant must include an
38
original signature.
1a. Have you ever been convicted of a MISDEMEANOR, had a judgment withheld or deferred, or are you currently charged with committing
Yes
No
a MISDEMEANOR?
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
Yes
No
FELONY?
You may also 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
N/A
Yes
No
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.)
N/A
Yes
No
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 answered “Yes” to any of the above questions (1a, 1b, or 1c), you must attach to this application:
a)
a written statement explaining the circumstances of each incident,
b)
a copy of the charging document, and
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
Yes
No
regarding any professional or occupational license or registration?
“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, 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, 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.
If you answered “Yes” to question 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
Yes
No
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 on behalf of others.
If you answered “Yes” to question 3, submit a statement summarizing the details of the indebtedness and arrangements for repayment,
and/or type and location of bankruptcy on a separate sheet.
4.
Have you been notified by any jurisdiction to which you are applying of any delinquent tax obligation that is not the subject
Yes
No
of a repayment agreement?
If you answered “Yes” to question 4, identify the jurisdiction(s):
Applicant’s Name
Accredited by the National Association of Insurance Commissioners (NAIC)
INS3245 (Rev. 1/2019)
Page 2 of 4
Ohio Department of Insurance
Individual Surplus Line Broker License Application
Background Questions (continued)
5.
Are you currently a party to, or have you ever been found liable in, any lawsuit, arbitrations or mediation proceeding involving allegations
Yes
No
of fraud, misappropriation or conversion of funds, misrepresentation or breach of fiduciary duty?
If you answered “Yes” to question 5, 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, arbitration, or mediation proceedings, and
c)
a copy of the official documents, which demonstrates the resolution of the charges or any final judgment.
6.
Have you or any business in which you are or were an owner, partner, officer, director, or member or manager of a liability company, ever
Yes
No
had an insurance agency contract or any other business relationship with an insurance company terminated for any alleged misconduct?
If you answered “Yes” to question 6, 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.
Do you have a child support obligation in arrearage?
Yes
No
If you answered “Yes” to question 7, answer the following:
a)
by how many months are you in arrearage?
Months
b)
are you currently subject to and in compliance with any repayment agreement?
Yes
No
c)
are you the subject of a child support related subpoena/warrant?
Yes
No
8.
Are you a member or veteran of the armed forces, or the spouse or surviving spouse of a service member or veteran?
Yes
No
Applicant’s Certification and Attestation
The Applicant must read the following very carefully:
39
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
Date
Full Legal Name (Printed or Typed)
Application Attachments
The following attachments must accompany the application; otherwise the application may be returned unprocessed or considered deficient.
40
1.
Non-refundable fee (check or money order) made payable to the “State of Ohio Treasurer” in the amount of $100.00;
2.
Proof of $25,000 bond executed in accordance with section 3905.35 of the Ohio Revised Code (Resident applicants only);
3.
Complete a State (BCI) and Federal (FBI) criminal background check (Resident applicants only);
4.
Completion of the attached Ohio Specific Bond Form (Resident applicants only); and
5.
If necessary, any required supporting details or documents.
Accredited by the National Association of Insurance Commissioners (NAIC)
INS3245 (Rev. 1/2019)
Page 3 of 4
Ohio Department of Insurance
Individual Surplus Line Broker License Application
SURPLUS LINES BROKER BOND
AS PROVIDED BY SECTION 3905.35, REVISED CODE OF OHIO
Bond Number:
Effective Date:
KNOW ALL MEN BY THESE PRESENTS;
We,
as Principal, an applicant for an Ohio
Surplus Lines Broker license, and
as Surety, hereon and admitted
To conduct surety business in Ohio, bind ourselves to the State of Ohio in the sum of twenty-five thousand ($25,000) dollars, for the
payment of such sum, which sum shall be the limit of total aggregate liability hereunder.
The condition of this obligation is such that whereas the said Principal has made application to the Superintendent of
Insurance for a license as a surplus lines broker, in accordance with section 3905.30 of the Revised Code of Ohio, and is required by
section 3905.35 of the Revised Code of Ohio to give bond payable to said state, in the sum of twenty-five thousand ($25,000) dollars,
and conditioned as set forth in section 3905.35 of the Revised Code of Ohio.
If such license is issued to the said Principal, the Principal shall faithfully comply with sections 3905.30 to 3905.36,
inclusive, of the Revised Code of Ohio.
The Surety shall be released from liability for future breaches of the condition of this bond upon giving sixty (60) days
written notice to the Principal and the Superintendent of Insurance of its desire to be released.
In witness whereof, the Principal has subscribed the Principal’s full and correct name on the date and at the place entered
opposite the Principal’s signature, and the Surety has subscribed its full and correct name and affix its corporate seal, if any, on the
date and at the place shown opposite its signature.
Principal
Date
Address
Surety
Date
Address
A COPY OF THE POWER OF ATTORNEY EVIDENCING AUTHORITY OF THE SIGNER OF THE BOND
ON BEHALF OF THE SURETY MUST BE ATTACHED.
Accredited by the National Association of Insurance Commissioners (NAIC)
INS3245 (Rev. 1/2019)
Page 4 of 4