"Insurance License Renewal Form" - Nebraska

Insurance License Renewal Form is a legal document that was released by the Nebraska Department of Insurance - a government authority operating within Nebraska.

Form Details:

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Download "Insurance License Renewal Form" - Nebraska

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STATE OF NEBRASKA
For DOI Use Only
DEPARTMENT OF INSURANCE
Identifier # ________________
PO Box 82089
Amount __________________
Lincoln, NE 68501
Dist # ___________________
www.doi.nebraska.gov
Check # __________________
MOTOR CLUB REPRESENTATIVE
INSURANCE LICENSE
RENEWAL FORM
REGISTRATION FORM
/
/
Name_
____________________________________
License #
_____________________ Expiration Date ___
___
______
1a.
Have
you been
convicted
of a
misdemeanor,
had a
judgment withheld
or
deferred,
or
are you
YES ___ NO ___
currently charged with
committing
a
misdemeanor,
which has not
been previously reported to
this
insurance department?
YES ___ NO ___
1b. Have you been convicted of a
felony,
had a
judgment withheld
or
deferred,
or
are
you
currently charged
with committing
a felony, which has
not been
previously
reported to
this
insurance department?
1c.
Have you been convicted
of
a military
offense,
had
a judgment
withheld or
deferred, or are you
YES ___ NO ___
currently
charged with
committing
a military
offense,
which
has not been previously reported
to
this insurance department?
** If
you answer yes to any of these questions,
you
must
attach
to
this
application:
a)
A
written statement
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. Have
you been named
or
involved as
a
party
in
an administrative
proceeding, including a FINRA
YES ___ NO ___
sanction or arbitration proceeding 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
or
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
answer
yes,
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
YES ___ NO ___
this
insurance department?
4.
In
response
to a
"yes"
answer
to
one or more of the
Background
Questions
for
this renewal
YES ___ NO ___
application, are
you
submitting document(s)
to the
NAIC/NIPR Attachments
Warehouse?
NA ___
5. Are
you
a
Citizen
of the
United
States?
If No,
you
must
provide proof
of
eligibility
to work in the
YES ___ NO ___
United States.
Signature: ________________________________________
Date: _______________________
I have changed my address. Please update my
__ Business __ Mailing __ Resident
address to the following:
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
STATE OF NEBRASKA
For DOI Use Only
DEPARTMENT OF INSURANCE
Identifier # ________________
PO Box 82089
Amount __________________
Lincoln, NE 68501
Dist # ___________________
www.doi.nebraska.gov
Check # __________________
MOTOR CLUB REPRESENTATIVE
INSURANCE LICENSE
RENEWAL FORM
REGISTRATION FORM
/
/
Name_
____________________________________
License #
_____________________ Expiration Date ___
___
______
1a.
Have
you been
convicted
of a
misdemeanor,
had a
judgment withheld
or
deferred,
or
are you
YES ___ NO ___
currently charged with
committing
a
misdemeanor,
which has not
been previously reported to
this
insurance department?
YES ___ NO ___
1b. Have you been convicted of a
felony,
had a
judgment withheld
or
deferred,
or
are
you
currently charged
with committing
a felony, which has
not been
previously
reported to
this
insurance department?
1c.
Have you been convicted
of
a military
offense,
had
a judgment
withheld or
deferred, or are you
YES ___ NO ___
currently
charged with
committing
a military
offense,
which
has not been previously reported
to
this insurance department?
** If
you answer yes to any of these questions,
you
must
attach
to
this
application:
a)
A
written statement
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. Have
you been named
or
involved as
a
party
in
an administrative
proceeding, including a FINRA
YES ___ NO ___
sanction or arbitration proceeding 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
or
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
answer
yes,
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
YES ___ NO ___
this
insurance department?
4.
In
response
to a
"yes"
answer
to
one or more of the
Background
Questions
for
this renewal
YES ___ NO ___
application, are
you
submitting document(s)
to the
NAIC/NIPR Attachments
Warehouse?
NA ___
5. Are
you
a
Citizen
of the
United
States?
If No,
you
must
provide proof
of
eligibility
to work in the
YES ___ NO ___
United States.
Signature: ________________________________________
Date: _______________________
I have changed my address. Please update my
__ Business __ Mailing __ Resident
address to the following:
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________