"Uniform Application for Business Entity License Renewal/Continuation"

Uniform Application for Business Entity License Renewal/Continuation is a 3-page legal document that was released by the National Association of Insurance Commissioners and used nation-wide.

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Download "Uniform Application for Business Entity License Renewal/Continuation"

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Please note the application may be revised on a bi-annual basis. To ensure you are filing the current version of the application, please
reference the National Insurance Producer Registry web site at www.nipr.com.
Uniform Application for
Business Entity License Renewal/Continuation
(Please Print or Type)
Check appropriate boxes for license requested.
Resident License
License #: _____________License Type: ______________
Non-Resident License License #:_____________ License Type: ______________
Demographic Information
Business Entity Name
FEIN
-
Home State & Home State License Number
If assigned, National Producer Number (NPN)
Is the business entity affiliated with a financial institution/bank?
Yes
No
Business Address
City
State
Zip Code or Foreign
Country
Phone Number (include extension)
Fax Number
Business Web Site Address
Business E-Mail Address
(
)
-
(
)
-
Mailing Address
P.O. Box
City
State
Zip Code or Foreign
Country
Designated/Responsible Licensed Producer
Identify at least one Designated/Responsible Licensed Producer responsible for the business entity’s compliance with the insurance laws, rules and regulations of this
state. (See Matrix of State Requirements at www.nipr.com for jurisdictions that require the 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
Background Questions
1a. Has the business entity or any owner, partner, officer or director of the business entity, or member or manager of a limited liability
company, been convicted of, or is currently charged with, committing a misdemeanor or had a judgment withheld or deferred for a
misdemeanor which has not been previously reported to this insurance department?
Yes ___ No___
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, or is currently charged with committing a felony or had a judgment withheld or deferred for a felony
Yes ___ No___
which has not been previously reported to this insurance department?
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 or is currently charged with a military offense which has not been previously reported to this
Yes ___ No___
insurance department?
© 2014 National Association of Insurance Commissioners
Page 1 of 3
Please note the application may be revised on a bi-annual basis. To ensure you are filing the current version of the application, please
reference the National Insurance Producer Registry web site at www.nipr.com.
Uniform Application for
Business Entity License Renewal/Continuation
(Please Print or Type)
Check appropriate boxes for license requested.
Resident License
License #: _____________License Type: ______________
Non-Resident License License #:_____________ License Type: ______________
Demographic Information
Business Entity Name
FEIN
-
Home State & Home State License Number
If assigned, National Producer Number (NPN)
Is the business entity affiliated with a financial institution/bank?
Yes
No
Business Address
City
State
Zip Code or Foreign
Country
Phone Number (include extension)
Fax Number
Business Web Site Address
Business E-Mail Address
(
)
-
(
)
-
Mailing Address
P.O. Box
City
State
Zip Code or Foreign
Country
Designated/Responsible Licensed Producer
Identify at least one Designated/Responsible Licensed Producer responsible for the business entity’s compliance with the insurance laws, rules and regulations of this
state. (See Matrix of State Requirements at www.nipr.com for jurisdictions that require the 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
Background Questions
1a. Has the business entity or any owner, partner, officer or director of the business entity, or member or manager of a limited liability
company, been convicted of, or is currently charged with, committing a misdemeanor or had a judgment withheld or deferred for a
misdemeanor which has not been previously reported to this insurance department?
Yes ___ No___
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, or is currently charged with committing a felony or had a judgment withheld or deferred for a felony
Yes ___ No___
which has not been previously reported to this insurance department?
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 or is currently charged with a military offense which has not been previously reported to this
Yes ___ No___
insurance department?
© 2014 National Association of Insurance Commissioners
Page 1 of 3
Please note the application may be revised on a bi-annual basis. To ensure you are filing the current version of the application, please
reference the National Insurance Producer Registry web site at www.nipr.com.
Uniform Application for
Business Entity License Renewal/Continuation
Applicant Name: ___________________________________
Background Questions continued
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, been named or involved as a party in an administrative proceeding, including a FINRA sanction or arbitration proceeding
regarding any professional or occupational license, or registration, which has not been previously reported to this insurance
department?
Yes ___ No___
“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. “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; identifying 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. In response to a “yes” answer to one or more of the Background Questions for this renewal application, are you submitting document(s)
Yes ___ No___
to the NAIC/NIPR Attachments Warehouse?        
If you answer yes;
Yes ___ No___
Will you be associating (linking) previously filed documents from the NAIC/NIPR Attachments Warehouse to this application?
Note: If you have previously submitted documents to the Attachments Warehouse that are intended to be filed with this renewal
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.
© 2014 National Association of Insurance Commissioners
Page 2 of 3
Please note the application may be revised on a bi-annual basis. To ensure you are filing the current version of the application, please
reference the National Insurance Producer Registry web site at www.nipr.com.
Uniform Application for
Business Entity License Renewal/Continuation
Applicant Name: ___________________________________
Applicant’s Certification and Attestation
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).
9
. 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 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 of a limited liability company:
____________________________________________
Month/Day/Year
____________________________________________
Signature
_________________________________________________
Typed or Printed Name
_________________________________________________
Title
_________________________________________________
Address
_________________________________________________
City
State
Zip
© 2014 National Association of Insurance Commissioners
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