"Insurance Business Entity License Application" - Nebraska

Insurance Business Entity License 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;
  • Ready to use and print;
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  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of the form by clicking the link below or browse more documents and templates provided by the Nebraska Department of Insurance.

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REQUIREMENTS AND PROCEDURES
FOR OBTAINING AN
INSURANCE BUSINESS ENTITY LICENSE
PROCEDURE
To obtain an insurance agency license
you can start the application process online at
www.nipr.com
and pay the license fee with a credit card, or you can submit a paper application and mail it to the
Nebraska Department of Insurance at the address below.
Applicants should also include:
• License Application fee (Refer to the License Fees listed below)
• Any additional documentation regarding “Yes” answers to the background questions,
including both court documents and an explanation of the event.
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
*Checks should be made out to the Nebraska Department of Insurance.
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:
https://sbs.naic.org/solar-external-lookup/license-manager.
DURATION OF LICENSE
All business entity licenses expire each year on April 30. License renewal reminders are emailed to the
agency approximately 60 days prior to the expiration date of the license.
BUSINESS ENTITY DEFINITION
Business Entity means a corporation, association, partnership, limited liability company, limited
liability partnership, or other legal entity. Neb.Rev.Stat §44-4049(1)
Note: Sole Proprietorships are required to obtain an insurance agency license if the sole proprietorship
falls within the business entity definition above or the sole proprietorship holds himself, herself or itself
out to be an insurance agency.
1
DOI-BE
Rev. 7_2020
REQUIREMENTS AND PROCEDURES
FOR OBTAINING AN
INSURANCE BUSINESS ENTITY LICENSE
PROCEDURE
To obtain an insurance agency license
you can start the application process online at
www.nipr.com
and pay the license fee with a credit card, or you can submit a paper application and mail it to the
Nebraska Department of Insurance at the address below.
Applicants should also include:
• License Application fee (Refer to the License Fees listed below)
• Any additional documentation regarding “Yes” answers to the background questions,
including both court documents and an explanation of the event.
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
*Checks should be made out to the Nebraska Department of Insurance.
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:
https://sbs.naic.org/solar-external-lookup/license-manager.
DURATION OF LICENSE
All business entity licenses expire each year on April 30. License renewal reminders are emailed to the
agency approximately 60 days prior to the expiration date of the license.
BUSINESS ENTITY DEFINITION
Business Entity means a corporation, association, partnership, limited liability company, limited
liability partnership, or other legal entity. Neb.Rev.Stat §44-4049(1)
Note: Sole Proprietorships are required to obtain an insurance agency license if the sole proprietorship
falls within the business entity definition above or the sole proprietorship holds himself, herself or itself
out to be an insurance agency.
1
DOI-BE
Rev. 7_2020
DESIGNATED RESPONSIBLE LICENSED PRODUCER
A licensed agency that sells, solicits or negotiates insurance must designate a responsible licensed
producer. The designated producer for the agency shall have full responsibility for the conduct of all
business transactions of the insurance agency within the state relative to insurance and shall be an active
member of the agency. Any individual associated with a licensed agency who solicits insurance shall be a
licensed producer. No agency shall pay any commission to anyone other than a licensed producer and no
licensed producer shall assign any commissions to any unlicensed agency.
If the designated producer loses his or her producer license or leaves or is removed from such position,
the agency shall replace the designated producer with a duly licensed producer within 30 days or its
license shall be revoked.
DISCIPLINARY ACTIONS, ADMINISTRATIVE FINE, PROCEDURE
The license of a business entity may be suspended, revoked, or refused if the director finds after notice
and hearing, that an individual licensee’s violation was known or should have been known by one or
more of the partners, officers, or managers acting on behalf of the business entity and the violation was
neither reported to the director nor corrective action taken. Neb.Rev.Stat §44-4059(3)
CONDUCT OF EXAMINATIONS; RECORD RETENTION REQUIREMENTS
Every company or person subject to the Insurers Examination Act shall retain all books, records,
accounts, papers, documents, and computer or other recordings relating to the property, assets,
financial accounts, and business of such company or person in a manner that permits examination of
such books, records, accounts, papers, documents, and computer or other recordings for five years, or
until the period of time in which the transaction took place has undergone a financial examination by
the director, whichever is later, following the completion of a transaction relating to the property, assets,
financial account, and business of such company or person. Neb.Rev.Stat §44- 5905(b)(i)(A)
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
Toll Free: (833) 410-5609
Fax: (402) 471-4610
Rev. 7_2020
DOI-BE
2
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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