"Self-storage Facility Limited Lines Agency Application" - Nebraska

Self-storage Facility Limited Lines Agency Application is a legal document that was released by the Nebraska Department of Insurance - a government authority operating within Nebraska.

Form Details:

  • Released on July 1, 2020;
  • The latest edition currently provided by the Nebraska Department of Insurance;
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  • Fill out the form in our online filing application.

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PROCEDURE AND REQUIREMENTS
FOR OBTAINING A SELF-STORAGE FACILITY
INSURANCE LICENSE
PROCEDURE
To obtain an agency Self-Storage Facility license, the NAIC Uniform Business Entity Application
or the NIPR online business entity application should be completed and submitted to the
Department of Insurance together with the following documents:
1. A list of self-service storage facilities at which the applicant conducts business in this
state.
2. A list of all employees of the applicant who may act on behalf and under the supervision
of the applicant.
3. A copy of the Training Program, which meets the requirements of 44-4069(9).
4. Certificate from Insurer stating that they will appoint or represent the applicant to act as
the insurance producer in reference to the doing of such kinds of self-storage insurance.
5. Application fee of $50.00.
A licensee shall provide a list, updated quarterly, of all self-storage facilities and all
employees who may act on behalf of the self-storage facility.
LICENSE FEES
Initial License Fee ……………………….………………………….……… $50.00
Renewal Fee ………………………………….………………………………. $50.00
Late Re-issuance Fee (within 30 days after expiration) ….…. $100.00
Reinstatement fee (after 30 days and up to 12 months).... $100.00
PRINTING LICENSES
The Nebraska Department of Insurance Licensing Division no longer mails out a hard copy of
new or renewed licenses. A copy of your license can be downloaded or printed by going to:
www.statebasedsystems.com/LicensePrint.htm.
DURATION OF LICENSE & RENEWALS
An agency Self-Storage Facility license is valid for one year from the date the license was issued.
Renewal instructions are mailed to the agency approximately 60 days prior to the expiration
date of the license. When renewing the license, please include any updated training materials
and a current listing of rental locations and authorized employees.
DOI-AGCY_SELFSTORAGE
Rev 7/2020
PROCEDURE AND REQUIREMENTS
FOR OBTAINING A SELF-STORAGE FACILITY
INSURANCE LICENSE
PROCEDURE
To obtain an agency Self-Storage Facility license, the NAIC Uniform Business Entity Application
or the NIPR online business entity application should be completed and submitted to the
Department of Insurance together with the following documents:
1. A list of self-service storage facilities at which the applicant conducts business in this
state.
2. A list of all employees of the applicant who may act on behalf and under the supervision
of the applicant.
3. A copy of the Training Program, which meets the requirements of 44-4069(9).
4. Certificate from Insurer stating that they will appoint or represent the applicant to act as
the insurance producer in reference to the doing of such kinds of self-storage insurance.
5. Application fee of $50.00.
A licensee shall provide a list, updated quarterly, of all self-storage facilities and all
employees who may act on behalf of the self-storage facility.
LICENSE FEES
Initial License Fee ……………………….………………………….……… $50.00
Renewal Fee ………………………………….………………………………. $50.00
Late Re-issuance Fee (within 30 days after expiration) ….…. $100.00
Reinstatement fee (after 30 days and up to 12 months).... $100.00
PRINTING LICENSES
The Nebraska Department of Insurance Licensing Division no longer mails out a hard copy of
new or renewed licenses. A copy of your license can be downloaded or printed by going to:
www.statebasedsystems.com/LicensePrint.htm.
DURATION OF LICENSE & RENEWALS
An agency Self-Storage Facility license is valid for one year from the date the license was issued.
Renewal instructions are mailed to the agency approximately 60 days prior to the expiration
date of the license. When renewing the license, please include any updated training materials
and a current listing of rental locations and authorized employees.
DOI-AGCY_SELFSTORAGE
Rev 7/2020
TRAINING PROGRAM REQUIREMENTS
Each limited licensee shall conduct a training program, which shall meet the following minimum
standards:
(a) Each trainee shall be instructed about the kinds of insurance specified in this section
offered for purchase by occupants;
(b) Each trainee shall be instructed that an occupant may have an insurance policy that
already provides the coverage being offered by the limited licensee pursuant to this
section and may not need to purchase from the limited licensee the insurance specified
in this section; and
(c) The training program shall be submitted and approved by the director and shall contain,
at a minimum, instructions on the types of insurance offered, ethical sales practices, and
required disclosures to prospective occupants.
Nebraska Revised Statute 44-4069:
https://nebraskalegislature.gov/laws/statutes.php?statute=44-4069
Reasonable accommodations for disabled persons available
upon request at (402) 471-2201. TDD users 800-833-7352 for relay to (402) 471-2201
NEBRASKA DEPARTMENT OF INSURANCE
INSURANCE LICENSING DIVISION
P.O. BOX 82089
LINCOLN, NE 68501-2089
E-mail: DOI.Licensing@Nebraska.gov
Licensing Division: (402) 471-4913
DOI Main Line: (402) 471-2201
Fax: (402) 471-4610
DOI-AGCY_SELFSTORAGE
Rev 7/2020
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/Registration
(Please Print or Type)
Check appropriate boxes for license requested.
Resident License
Non-Resident License
Identify Home State:_______________
o
Identify Home State License #:_____________
o
New Application
Additional Line(s) of Authority
Demographic Information
Business Entity Name
2
Incorporation/Formation Date
3
FEIN
1
(month) ___(day) ___(year) _____
-
4
If assigned, National Producer Number (NPN)
If applicable, FINRA Firm Central Registration Depository (CRD)
5
List any other assumed, fictitious, alias or trade names under which you are currently
State of Domicile
Country of Domicile
7
8
6
doing business or intend to do business.
Is the business entity affiliated with a financial institution/bank?
Yes
No
9
(Specify)
10
Business Address
11
City
12
State
Zip Code
14
Foreign Country
13
Phone Number (include Ext.)
Fax Number
Business Web Site Address
Business E-Mail Address
15
16
17
18
(
)
-
(
)
-
Mailing Address
P.O. Box
City
State
Zip Code
Foreign Country
19
20
22
23
24
21
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
25
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
Owners, Partners, Officers and Directors
26
Identify all owners with 10% interest or voting interest, partners, officers and directors of the business entity, or members or managers of a limited liability company:
Name
Title
SSN/FEIN
-
-
D.O.B ___________Owner: Yes / No % of ownership interest ____
Name
Title
SSN/FEIN
-
-
D.O.B ___________Owner: Yes / No % of ownership interest ____
Name
Title
SSN/FEIN
-
-
D.O.B ___________Owner: Yes / No % of ownership interest ____
Name
Title
SSN/FEIN
-
-
D.O.B ___________Owner: Yes / No % of ownership interest ____
Name
Title
SSN/FEIN
-
-
D.O.B ___________Owner: Yes / No % of ownership interest ____
Name
Title
SSN/FEIN
-
-
D.O.B ___________Owner: Yes / No % of ownership interest ____
Name
Title
SSN/FEIN
-
-
D.O.B ___________Owner: Yes / No % of ownership interest ____
Name
Title
SSN/FEIN
-
-
D.O.B ___________Owner: Yes / No % of ownership interest ____
(State Use)
© 2014 National Association of Insurance Commissioners
Page 1 of 6
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/Registration
Applicant Name: _______________________________
Jurisdiction and Type of License/Registration Requested –Major Lines of Authority
27
Next to each jurisdiction, check the legal business type, license/registration type(s) and line(s) of authority for which you are applying.
LLP – Limited Liability
Legal Business Type:
C – Corporation
P – Partnership
S – Sole Proprietorship
LLC – Limited Liability Company
Partnership
License/Registration
A – Agent
B – Broker
P – Producer
SLP – Surplus Lines Producer
Types:
V – Variable
H – Accident & Health or
Lines of Authority:
L – Life
P – Property
C – Casualty
P L– Personal Lines
Life/Variable Annuity
Sickness
Jurisdiction
Legal Business Type
License/Registration Type
Lines of Authority
C
P
S
LLC
LLP
A
B
P
SLP
V
L
H
P
C
PL
AK
AL
AR
AZ
CA
CO
CT
DC
DE
FL
GA
GU
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
PR
RI
SC
SD
TN
TX
UT
VA
VI
VT
WA
WI
WV
WY
© 2014 National Association of Insurance Commissioners
Page 2 of 6
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/Registration
Applicant Name:______________________________________
Jurisdiction and Type of License/Registration - Limited Lines of Authority
28
Next to each jurisdiction, check the legal business type, license/registration type(s) and line(s) of authority for which you are applying.
LLP – Limited Liability
Legal Business Type:
C – Corporation
P – Partnership
S – Sole Proprietorship
LLC – Limited Liability Company
Partnership
License/Registration
A – Agent
B – Broker
P – Producer
SLP – Surplus Lines Producer
Types :
Limited Lines:
Credit – Credit
CR – Car Rental
CROP – Crop
T – Travel
S – Surety
O – Other: Specify Type
Jurisdiction
Legal Business Type
License/Registration Type
Lines of Authority
Specify Below
C
P
S
LLC
LLP
A
B
P
SLP
Credit
CR
Crop
T
S
O____________
AK
AL
AR
AZ
CA
CO
CT
DC
DE
FL
GA
GU
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
PR
RI
SC
SD
TN
TX
UT
VA
VI
VT
WA
WI
WV
WY
© 2014 National Association of Insurance Commissioners
Page 3 of 6
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