
Form AID-LI-TAGY(9/07)
Page 2
Jurisdiction and Type of License/Registration Requested –
Next to each jurisdiction, check the legal business type, license/registration type(s) and line(s) of authority for which you are applying.
Legal Business Type:
C – Corporation P – Partnership LLC – Limited Liability Company LLP – Limited Liability Partnership
Background Information
Please read the following very carefully and answer every question. All copies of documents must be certified. All written statements
submitted by the Applicant must include an original signature.
1. Has the business entity or any owner, partner, officer or director ever been convicted of, or is the business entity or any owner, partner,
officer or director currently charged with, committing a crime, whether or not adjudication was withheld?
Yes ___ No___
“Crime” includes a misdemeanor , felony or a military offense. You may exclude misdemeanor traffic citations and juvenile offenses.
“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
contendre, or having been given probation, a suspended sentence or a fine.
If you answer yes, you must attach to this application:
a) a written statement explaining the circumstances of each incident,
b) a certified copy of the charging document, and
c) a certified 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 ever been involved in an administrative proceeding regarding any
professional or occupational license?
Yes ___ No___
“Involved” means having a license censured, suspended, revoked, canceled, terminated; or, being assessed a fine, a cease and
desist order, a prohibition order, a compliance order, placed on probation 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 and explaining the circumstances of each incident,
b) a certified copy of the Notice of Hearing or other document that states the charges and allegations, and
c) a certified copy of the official document which demonstrates the resolution of the charges or any final judgment.
3. Has any demand been made or judgment rendered against the business entity or any owner, partner, officer or director for overdue
monies by an insurer, insured or producer, or have you ever been subject to a bankruptcy proceeding?
Yes ___ No___
If you answer yes, submit a statement summarizing the details of the indebtedness and arrangements for repayment.
4. Has the business entity or any owner, partner, officer or director ever been notified by any jurisdiction to which you are applying of any
delinquent tax obligation that is not the subject of a repayment agreement?
Yes ___ No___
If you answer yes, identify the jurisdiction(s): _______________________________________
5. Is the business entity or any owner, partner, officer or director a party to, or ever been found liable in any lawsuit or arbitration proceeding
involving allegations of fraud, misappropriation or conversion of funds, misrepresentation or breach of fiduciary duty?
Yes ___ No___
If you answer yes, you must attach to this application:
a) a written statement summarizing the details of each incident,
b) a certified copy of the Petition, Complaint or other document that commenced the lawsuit or arbitration, and
c) a certified copy of the official document which demonstrates the resolution of the charges or any final judgment.
6. Has the business entity or any owner, partner, officer or director ever had an insurance agency contract or any other business relationship
with an insurance company terminated for any alleged misconduct?
Yes ___ No___
If you answer yes, you must attach to this application:
a) a written statement summarizing the details of each incident and explaining why you feel this incident should not prevent you
from receiving an insurance license, and
b) certified copies of all relevant documents.
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