Form INS32519 "Individual Viatical Settlement Broker License Renewal/Continuation" - Ohio

What Is Form INS32519?

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 INS32519 by clicking the link below or browse more documents and templates provided by the Ohio Department of Insurance.

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Download Form INS32519 "Individual Viatical Settlement Broker License Renewal/Continuation" - 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 Viatical Settlement Broker
Fax # (614) 387-0096
www.insurance.ohio.gov
License Renewal/Continuation
(Please Print or Type)
Check appropriate box for license requested:
Resident OH License #:
Non-Resident OH License #:
Identify Home State:
Identify Home State License #:
Demographic Information
1
National Producer Number (NPN)
2
Date of Birth
Last Name
JR./SR. etc
First Name
3
4
Residence/Home Address (Physical Street)
City
State
Zip or Foreign Country
8
6
5
7
Individual Applicants Email Address
9
Business Entity’s Name
10
Business Address (Physical Street)
P.O. Box
City
State
Zip or Foreign Country
11
12
13
15
14
Business Phone Number
Business Fax Number
18
Business E-Mail Address
19
Business Web Site Address
16
17
(include extension)
Mailing Address
P.O. Box
City
State
Zip or Foreign Country
23
20
21
22
24
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)
25
FEIN
NPN
Name of Agency
FEIN
NPN
Name of Agency
Background Questions
The Applicant must read the following very carefully and answer every question. All written statements submitted by the Applicant must include an
26
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, which has not been previously reported to this insurance department?
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, which has not been previously reported to this insurance department?
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
Accredited by the National Association of Insurance Commissioners (NAIC)
INS32519 (Rev. 01/2019)
Page 1 of 3
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 Viatical Settlement Broker
Fax # (614) 387-0096
www.insurance.ohio.gov
License Renewal/Continuation
(Please Print or Type)
Check appropriate box for license requested:
Resident OH License #:
Non-Resident OH License #:
Identify Home State:
Identify Home State License #:
Demographic Information
1
National Producer Number (NPN)
2
Date of Birth
Last Name
JR./SR. etc
First Name
3
4
Residence/Home Address (Physical Street)
City
State
Zip or Foreign Country
8
6
5
7
Individual Applicants Email Address
9
Business Entity’s Name
10
Business Address (Physical Street)
P.O. Box
City
State
Zip or Foreign Country
11
12
13
15
14
Business Phone Number
Business Fax Number
18
Business E-Mail Address
19
Business Web Site Address
16
17
(include extension)
Mailing Address
P.O. Box
City
State
Zip or Foreign Country
23
20
21
22
24
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)
25
FEIN
NPN
Name of Agency
FEIN
NPN
Name of Agency
Background Questions
The Applicant must read the following very carefully and answer every question. All written statements submitted by the Applicant must include an
26
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, which has not been previously reported to this insurance department?
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, which has not been previously reported to this insurance department?
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
Accredited by the National Association of Insurance Commissioners (NAIC)
INS32519 (Rev. 01/2019)
Page 1 of 3
Ohio Department of Insurance
Individual Viatical Settlement Broker License Renewal/Continuation
Background Questions (Continued)
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, which has not been previously reported to this insurance department?
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, which has not been previously reported to this insurance department?
“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, 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.
Do you have a child support obligation in arrearage, which has not been previously reported to this insurance department?
Yes
No
If you answered “Yes” to question 3, answer the following:
a)
by how many months are you in arrearage?
Months
Yes
No
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?
4.
Since your last application or renewal have you been under investigation by any regulatory authority?
Yes
No
If Yes, details must be provided.
5.
Since your last application or renewal have you been subject to any regulatory action including cease and desist orders or similar actions?
Yes
No
If Yes, details must be provided.
6.
Since your last application or renewal have you been a defendant in any lawsuit asking for a judgment that is equal to or greater than 10%
Yes
No
of your total assets?
If Yes, details must be provided.
7.
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 Name
Accredited by the National Association of Insurance Commissioners (NAIC)
INS32519 (Rev. 01/2019)
Page 2 of 3
Ohio Department of Insurance
Individual Viatical Settlement Broker License Renewal/Continuation
Applicant’s Certification and Attestation
The Producer must read the following very carefully:
27
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.
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 Producer 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.
28
1.
Non-refundable fee (check or money order) made payable to the “State of Ohio Treasurer” in the amount of $100.00;
2.
Must provide a description of procedures that are in place to safeguard the confidentiality of viators’ and insureds’ personal and medical information that complies
with division (G) of ORC section 3916.07 and 3916.13, only if any changes have been made since the last application or renewal;
3.
Must provide a comprehensive anti-fraud plan that complies with requirements of division (G) of ORC section 3916.18, only if any changes have been made since
the last application or renewal;
4.
Must provide an organizational chart that identifies all employees, position titles, and description of position(s) for any new or remove employees. Chart must
include the dates that the change became effective; and
5.
If necessary, any required supporting details or documents.
Continuing Education Requirements – Residents Only
29
1.
Resident Viatical Settlement Brokers must complete CE requirements every 2 years. The renewal application should not be submitted until after CE credits have
been completed.
st
1.
Completion of 15 VSE credit requirement on or before compliance period deadline date (biennially December 31
);
2.
VSE Course Completion Certificate(s), if required; and
3.
VSE compliance period extension fee of $100.00, if required;
Accredited by the National Association of Insurance Commissioners (NAIC)
INS32519 (Rev. 01/2019)
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