Form FIN507 "Application for Insurance Agency License" - Texas

What Is Form FIN507?

This is a legal form that was released by the Texas Department of Insurance - a government authority operating within Texas. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on September 1, 2021;
  • The latest edition provided by the Texas 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 FIN507 by clicking the link below or browse more documents and templates provided by the Texas Department of Insurance.

ADVERTISEMENT
ADVERTISEMENT

Download Form FIN507 "Application for Insurance Agency License" - Texas

Download PDF

Fill PDF online

Rate (4.7 / 5) 19 votes
Page background image
FIN507 | 0921
Application for insurance agency license
All applicants read Part 7 - General Information beginning on page 11.
This application must be used by an entity to apply for a Texas insurance license. The application must be either
typed or printed in ink. All requested information must be submitted with this application. All applications are
subject to further review. Any affirmative response to a screening question may extend processing times. Failure
to disclose criminal history information may result in denial of license.
Part 1 – Application Information (to be completed by all applicants)
License Types: (check only one per application)
Risk Manager
County Mutual
Funeral Prearrangement Life
Life Insurance Not Exceeding $25,000
License Fees: Fees are $50.00 per license type. $75 fee required for license that has been expired for more than
90 days but less than one year. Make check or money order payable to the Texas Department of Insurance. All
license fees are nonrefundable and nontransferable.
Entity Type: See descriptions on page 13 and check your entity type.
Corporation
Partnership
Farm Credit Administration
Depository Institution
Entity Information: Read carefully and provide all requested information.
Entity Name
(Print full legal name of entity. The name must be the same as on the official formation document.)
1. Entity’s Federal Employer Identification Number (FEIN) assigned by the U.S. Internal Revenue
Service and Daytime Phone Number: This application cannot be processed without this information.
FEIN
(Numbers assigned by the Texas Comptroller will not be accepted)
Day Time Phone Number
Ext
2. Official Mailing Address: This is the address of record with TDI.
Street address or route
City
State
ZIP
3. Business Address: This address must be your primary office address where the applicant will maintain
business records of Texas insurance transactions.
1 / 13
FIN507 | 0921
Application for insurance agency license
All applicants read Part 7 - General Information beginning on page 11.
This application must be used by an entity to apply for a Texas insurance license. The application must be either
typed or printed in ink. All requested information must be submitted with this application. All applications are
subject to further review. Any affirmative response to a screening question may extend processing times. Failure
to disclose criminal history information may result in denial of license.
Part 1 – Application Information (to be completed by all applicants)
License Types: (check only one per application)
Risk Manager
County Mutual
Funeral Prearrangement Life
Life Insurance Not Exceeding $25,000
License Fees: Fees are $50.00 per license type. $75 fee required for license that has been expired for more than
90 days but less than one year. Make check or money order payable to the Texas Department of Insurance. All
license fees are nonrefundable and nontransferable.
Entity Type: See descriptions on page 13 and check your entity type.
Corporation
Partnership
Farm Credit Administration
Depository Institution
Entity Information: Read carefully and provide all requested information.
Entity Name
(Print full legal name of entity. The name must be the same as on the official formation document.)
1. Entity’s Federal Employer Identification Number (FEIN) assigned by the U.S. Internal Revenue
Service and Daytime Phone Number: This application cannot be processed without this information.
FEIN
(Numbers assigned by the Texas Comptroller will not be accepted)
Day Time Phone Number
Ext
2. Official Mailing Address: This is the address of record with TDI.
Street address or route
City
State
ZIP
3. Business Address: This address must be your primary office address where the applicant will maintain
business records of Texas insurance transactions.
1 / 13
Street address or route
City
State
ZIP
4. Entity’s email address (required): Email will be preferred method of communication when
corresponding with TDI.
Email address
5. Resident Status:
Texas Entity
Nonresident Entity
State of Residence
6. Does the entity currently hold a license in its state of residence that is the same or similar to the license
being applied for in this application?
No
Yes
If yes, the department will verify your active resident license status in the National Association of Insurance
Commissioner’s Producer Database (PDB). If you are not currently listed in the PDB, you must obtain and
attach a Certificate of Good Standing from your resident state that is not more than 90 days old.
7. Is the applicant entity affiliated with a financial institution/bank?
No
Yes
This question is to facilitate requests for information from other regulators.
Part 2 – Biographical Information
Responsible Individual(s) / Entity(s) and fingerprint requirement
This page must be completed for responsible individuals with all applicable information described below. Page
3 must be completed for responsible entities with all applicable information described below.
Responsible Individual(s) / Entity(s): Identify and provide all required information for all executive officers,
directors, or partners who administer the applicant entity’s insurance operations in Texas and all individuals and
entities “in control” of the applicant entity’s insurance operations. See page 9 for the definition of “control” and
other related information. At least one officer or active partner must hold the same license as the entity is
applying for in this application. Limited partnerships must list a general partner who holds the same license type
as that being applied for by the limited partnership.
For each individual listed on page 2, provide the individual’s full legal name, title in relation to the applicant
entity, complete mailing address, social security number, date of birth, fingerprint information and the Texas
license number, if individual holds such license.
Fingerprints: Each individual listed on page 2 must provide a copy of a fingerprint receipt from IdentoGo. See
our
Fingerprint Requirements and Instructions
for detailed information.
The fingerprint requirement is waived if one of the following applies:
1. The individual holds an active TDI license and has already submitted fingerprints to TDI with another
license application, or
2. The individual is a nonresident and meets this requirement by one of the following:
2 / 13
a. The individual holds a current similar license in good standing in the individual’s home state as
reflected on the National Association of Insurance Commissioner’s Producer Database, or
b. The individual provides with this application criminal history records obtained from the
individual’s resident state’s law enforcement agency, or
3. The nonresident applicant entity holds an active entity license that is similar to the license requested on
this application in their resident state.
For each responsible entity listed on page 3, provide the entity’s full legal name, complete mailing address,
federal employee identification number (FEIN) and an attachment detailing the name and address of all
individuals and entities that have controlling relationships affecting the applicant entity up to the ultimate
controlling individual or entity. If an entity is a trust, also give the name and address of the trustee. The
attachment may be in the form of an organization chart.
Responsible Individuals
Make as many additional copies of this page as necessary. Please mark one of the selection boxes if fingerprint
is not required.
1. Name
First name
Middle name
Last name
Suffix
Title
Social Security Number
Date of Birth (MM/DD/YYYY)
TDI License Number
Street address or route
City
State
ZIP
Individual or entity is currently licensed in the resident state with a license similar to the license applied
for on this application, or
Individual is a nonresident and has attached criminal history records from individual’s resident state’s
law enforcement agency.
2. Name
First name
Middle name
Last name
Suffix
Title
Social Security Number
Date of Birth (MM/DD/YYYY)
TDI License Number
Street address or route
City
State
ZIP
Fingerprint receipt from IdentoGO is attached (see our
Fingerprint Requirements and Instructions
document for complete fingerprinting instructions), or
Individual has active TDI License No. ________________, and previously submitted fingerprints to TDI, or
3 / 13
Individual is currently licensed in the individual’s resident state with a license similar to the license
applied for on this application, or
Individual is a nonresident and has attached criminal history records from individual’s resident state’s
law enforcement agency, or
Applicant nonresident entity is currently licensed in resident state.
3. Name
First name
Middle name
Last name
Suffix
Title
Social Security Number
Date of Birth (MM/DD/YYYY)
TDI License Number
Street address or route
City
State
ZIP
Fingerprint receipt from IdentoGO is attached (see our
Fingerprint Requirements and Instructions
document for complete fingerprinting instructions), or
Individual has active TDI License No. ________________, and previously submitted fingerprints to TDI, or
Individual is currently licensed in the individual’s resident state with a license similar to the license
applied for on this application, or
Individual is a nonresident and has attached criminal history records from individual’s resident state’s
law enforcement agency, or
Applicant nonresident entity is currently licensed in resident state
4 / 13
Responsible Entities
Refer to page 2 for instructions to complete this page. Make as many additional copies of this page as necessary.
1. Entity’s full legal name
FEIN
Street address or route
City
State
ZIP
A summary of control relationships affecting the applicant entity, including full names with mailing
addresses is attached.
2. Entity’s full legal name
FEIN
Street address or route
City
State
ZIP
A summary of control relationships affecting the applicant entity, including full names with mailing
addresses is attached.
3. Entity’s full legal name
FEIN
Street address or route
City
State
ZIP
A summary of control relationships affecting the applicant entity, including full names with mailing
addresses is attached.
4. Entity’s full legal name
FEIN
Street address or route
City
State
ZIP
A summary of control relationships affecting the applicant entity, including full names with mailing
addresses is attached.
5. Entity’s full legal name
FEIN
Street address or route
City
State
ZIP
A summary of control relationships affecting the applicant entity, including full names with mailing
addresses is attached.
5 / 13
Page of 13