United States Insurance Producer
Resume:
RegEd Producer Application Paper Format
What is the applicant's name? *,,
First Name, *
Last Name, *
I give Teleperformance License Team permission to use this form to complete my Application process in RegEd and NIPR.
Is the applicant a citizen of the United States? *
Yes
No
Is this application for Massachusetts Insurance Producer? *
Yes
No
Are you a member or veteran of the armed forces, or the spouse or surviving spouse of a service member or veteran? *
Yes
No
Has the applicant read the Tennessen Warning? (Tennessen Warning is provided in the HELP resource) *
Yes
No
Did the applicant choose any of the Variable lines on the preceding screens for any state? (A CRD number must be entered if applying for a Variable line of authority in any state). *
Yes
No
Enter the applicant's CRD number.(FINRA Individual Central Registration Depository number).
Yes
No
For NY - Does the applicant currently hold an active Surplus/Excess Lines License in his/her Resident State? *
Yes
No
IMPORTANT: AS A CALIFORNIA LICENSE APPLICANT, YOU MUST ANSWER THE FOLLOWING QUESTION BEFORE YOUR APPLICATION CAN BE SUBMITTED. PLEASE NOTE THAT QUESTION #1A ON THE BACKGROUND QUESTIONS PAGE THAT FOLLOWS IN THIS APPLICATION HAS A DIFFERENT DEFINITION OF CRIME THAN CALIFORNIA HAS ON THIS PAGE AND WILL NEED TO BE ANSWERED ACCORDINGLY. Please read the following definition of crime. California Applicant: "Crime" includes a felony, a misdemeanor or military offense. "Convicted" includes, but is not limited to, having been found guilty by a verdict of a judge or jury, having entered a plea of nolo contendere, no contest, having had any charge expunged, dismissed or plea withdrawn pursuant to Penal Code Section 1203.4, or having been given probation, a suspended sentence or a fine. You may exclude traffic citations and juvenile offenses tried in juvenile court. You should also answer "yes" if you have been convicted of a felony or a misdemeanor including driving offenses such as, but not limited to reckless driving, driving under the influence and driving with a suspended license, whether or not you spent any time in jail, and whether or not you believe the conviction has been removed from your record. Have you been convicted of a crime? IMPORTANT: ONCE AGAIN, PLEASE NOTE THAT QUESTION #1A ON THE BACKGROUND QUESTIONS PAGE THAT FOLLOWS IN THIS APPLICATION HAS A DIFFERENT DEFINITION OF CRIME THAN CALIFORNIA HAS ON THIS PAGE AND WILL NEED TO BE ANSWERED ACCORDINGLY. *
Yes
No
NAIC #1A - Has the applicant ever been convicted of a misdemeanor, had a judgment withheld or deferred, or currently charged with committing a misdemeanor? ("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 contendere or no contest, or having been given probation, a suspended sentence, or a fine. Applicant may exclude the following misdemeanor convictions or pending misdemeanor charges: traffic citations, driving under the influence (DUI), driving while intoxicated (DWI), driving without a license, reckless driving, or driving with a suspended or revoked license. Applicant may also exclude juvenile adjudications (offenses where he was adjudicated delinquent in a juvenile court)). Be sure to check the HELP resource to review the information required for a 'Yes' answer. *
Yes
No
NAIC #1B - Has the applicant ever been convicted of a felony, had a judgment withheld or deferred, or currently charged with committing a felony? ("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 contendere or no contest, or having been given probation, a suspended sentence, or a fine. Applicant may exclude juvenile adjudications (offenses where applicant were adjudicated delinquent in a juvenile court)). Be sure to check the HELP resource to review the information required for a 'Yes' answer. *
Yes
No
NAIC #1BA - If the applicant has a felony conviction involving dishonesty or breach of trust, has the applicant applied for written consent to engage in the business of insurance in the applicant home state as required by 18 USC 1033? *
Yes
No
NAIC #1BB - If so, was that consent granted? (Attach copy of 1033 consent approved by home state.) *
Yes
No
NAIC #1C - Has the applicant ever been convicted of a military offense, had a judgment withheld or deferred, or currently charged with committing a military offense? ("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 contendere or no contest, or having been given probation, a suspended sentence, or a fine). Be sure to check the HELP resource to review the information required for a 'Yes' answer. *
Yes
No
16.
For the purposes of the California application, you have been "convicted" if you were ever found guilty by verdict of a judge or jury; and/or ever entered a plea of guilty, nolo contendre or no contest. You must disclose all convictions, even if the charges were later dismissed or expunged, your guilty plea was withdrawn pursuant to Penal Code Section 1203.4, or you were placed on probation, received a suspended sentence or just ordered to pay a fine. You must also disclose all driving related misdemeanors including, but not limited to, driving under the influence, reckless driving, driving without a valid license, or driving with a suspended or revoked license. If you fail to disclose all convictions, your application may be denied. You may exclude juvenile offenses tried in juvenile court. HAVE YOU DISCLOSED ALL INFORMATION REQUIRED BY CALIFORNIA? *
Yes
No
17.
NAIC #2 - Has the applicant ever been named or involved as a party in an administrative proceeding, including FINRA sanction or arbitration proceeding regarding any professional or occupational license or registration? ("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, 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 the applicant's actions, in his capacity as an owner, partner, officer, director, or member or manager of a Limited Liability Company. Applicant may EXCLUDE terminations due solely to noncompliance with continuing education requirements or failure to pay a renewal fee.) Be sure to check the HELP resource to review the information required for a 'Yes' answer. *
Yes
No
18.
NAIC #3 - Has any demand been made or judgment rendered against the applicant or any business in which the application is or was an owner, partner, officer or director, or member or manager of a limited liability company, for overdue monies by an insurer, insured or producer or has the applicant ever been subject to a bankruptcy proceeding? Do not include personal bankruptcies, unless they involve funds held on behalf of others. If answered "Yes", a statement summarizing the details of the indebtedness and arrangements for repayment, and / or type and location of bankruptcy must be submitted. *
Yes
No
19.
NAIC #4 - Has the applicant been notified by any jurisdiction to which they are applying of any delinquent tax obligation that is not the subject of a repayment agreement? *
Yes
No
20.
IMPORTANT: AS A CALIFORNIA LICENSE APPLICANT, YOU MUST ANSWER THE FOLLOWING QUESTION BEFORE YOUR APPLICATION CAN BE SUBMITTED. PLEASE NOTE QUESTION #5 ON THE BACKGROUND QUESTIONS PAGE THAT FOLLOWS IN THIS APPLICATION HAS AN ADDITIONAL BACKGROUND ISSUE THAT MUST BE DISCLOSED THAT CALIFORNIA HAS ON THIS PAGE AND WILL NEED TO BE ANSWERED ACCORDINGLY. Are you currently a party to, or have you ever been found liable in, any lawsuit, arbitrations or mediation proceeding involving allegations of fraud, misappropriation or conversion of funds, misrepresentation or breach of fiduciary duty? Please read the following additional disclosure requirement for the California applicants and licensees: The individual license applicant or business entity controlling person who has been found liable by clear and convincing evidence in a civil action involving allegations of elder or dependent abuse, oppression, fraud, malice, misappropriation or conversion of funds, misrepresentation, or breach of fiduciary duty must be disclosed on this application. [California Insurance Code sections 1668(r) and 1668.5(a)(9)] *
Yes
No
21.
NAIC #5 - Is the applicant currently a party to, or has the applicant ever been found liable in, any lawsuit, arbitrations or mediation proceeding involving allegations of fraud, misappropriation or conversion of funds, misrepresentation or breach of fiduciary duty? Be sure to check the HELP resource to review the information required for a 'Yes' answer. *
Yes
No
22.
NAIC #6 - Has the applicant or any business in which the applicant is or was an owner, partner, officer, director, or member or manager of a limited liability company, ever had an insurance agency contract or any other business relationship with an insurance company terminated for any alleged misconduct? Be sure to check the HELP resource to review the information required for a 'Yes' answer. *
Yes
No
23.
NAIC #7 - Does the applicant have a child support obligation in arrearage? Be sure to check the HELP resource to review the information required for a 'Yes' answer. *
Yes
No
24.
NAIC #7B - Is the applicant currently subject to and in compliance with any repayment agreement? *
Yes
No
25.
NAIC #7C - Is the applicant the subject of a child support related subpoena/warrant? *
Yes
No
26.
For Georgia license - Has the applicant been convicted of or currently charged with the commission of any crime or pled nolo contendere in a criminal proceeding or has the applicant received first offender treatment or had adjudication of guilt withheld in a criminal proceeding, other than a minor traffic offense? *
Yes
No
27.
For all states except CA and GA - NAIC/NIPR Attachment Warehouse - If the applicant answered "Yes" to one or more of the background questions for this application/renewal, is the applicant submitting supporting documents(s) to the NAIC/NIPR attachments Warehouse. If the applicant has not answered "Yes" to any background question, please select N/A. *
Yes
No
N/A
28.
For CA - NAIC/NIPR Attachment Warehouse - If the applicant answered "Yes" to one or more of the background questions for this application/renewal, is the applicant submitting supporting documents(s) to the NAIC/NIPR attachments Warehouse. If the applicant has not answered "Yes" to any background question, please select N/A. *
Yes
No
N/A
29.
For GA - NAIC/NIPR Attachment Warehouse - If the applicant answered "Yes" to one or more of the background questions for this application/renewal, is the applicant submitting supporting documents(s) to the NAIC/NIPR attachments Warehouse. If the applicant has not answered "Yes" to any background question, please select N/A. *
Yes
No
N/A
30.
If the applicant is submitting supporting documents(s) to the NAIC/NIPR attachments Warehouse will the applicant be associating(linking) previously filed documents from the NAIC/NIPR Attachments Warehouse to this application? *
Yes
No
31.
Is this application for California Surplus Lines Broker? *
Yes
No
32.
CA - For applicants applying for Surplus Line Broker in CA, please select from the following two options: *
I am an individual applicant applying for Surplus Lines who only transacts on behalf of a Surplus Lines business entity.
I am an individual applicant applying for Surplus Lines that has a $50,000 bond on file.
33.
Is this application for California Special Lines SL Broker? *
Yes
No
34.
CA - For applicants applying for Special Lines SL Broker in CA, please select from the following two options: *
I am an individual applicant applying for Surplus Lines who only transacts on behalf of a Special Lines' Surplus Line Broker business entity.
I am an individual applicant applying for Special Lines' Surplus Line Broker that has a $10,000 bond on file.
35.
CA - To assist the Department with reporting and outreach efforts, licensees are asked to voluntarily provide their race/ethnicity, sexual orientation, and veteran/disabled veteran status. Please select the following Race/Ethnicity that applies:
African American/Black
American Indian or Alaska Native
Asian American/Asian
Caucasian/White
Hispanic/Latino
Native Hawaiian or Other Pacific Islander
Prefer not to answer
36.
CA - Do you publicly identify as LGBT+ (Lesbian, Gay, Bisexual, and/or Transgender)?
Yes
No
Prefer not to answer
37.
CA - Are you a veteran?
Yes
No
Prefer not to answer
38.
CA - Are you a disabled veteran?
Yes
No
Prefer not to answer
39.
CALIFORNIA DISCLOSURE AGREEMENT: I consent to the publication, on the public Department of Insurance licensee directories, of any business telephone number I provide for licensing purposes, including, but not limited to, personal, residential, or cellular telephone numbers used for business purposes. This consent is valid for the term of my license and for five years after license expiration, consistent with the authority granted in California Insurance Code Section 1743.NOTE: Pursuant to California Civil Code Section 1798.61, the Department publishes the names and business addresses of licensees, and is not required to obtain consent to release that information. *
Yes
No
40.
Is the applicant re-applying/reinstating the same license class that was previously held in New York? *
Yes
No
41.
Since expiration of your last authority, have you transacted business in New York under the license you are applying for in this application? *
Yes
No
42.
PA - To assist the Department with reporting and outreach efforts, licensees are asked to voluntarily provide their race/ethnicity, sexual orientation. Please select the following Race/Ethnicity that applies:
African American/Black
American Indian or Alaska Native
Asian American/Asian
Caucasian/White
Hispanic/Latino
Native Hawaiian or Other Pacific Islander
Prefer not to answer
43.
PA - Do you publicly identify as LGBT+ (Lesbian, Gay, Bisexual, and/or Transgender, etc.)?
Yes
No
Prefer not to answer
44.
Has the applicant read the TX State Specific Requirements? https://www.nipr.com/rules_tx_nrl.htm *
Yes
No
45.
Is this application for New Mexico Insurance Producer Title? *
Yes
No
46.
Applicant must own, operate or control an abstract plant consisting of a set of records which have been filed or recorded in the county for which such plant is maintained for a period of not less than twenty (20) years. Do you meet this requirement? *
Yes
No
47.
If answered Yes, please complete the following information: What counties are you doing business in? (must be licensed in each county): *
County/counties (Comma delimited list of counties)
*
Date of plant inspection
*
Plant name
*
Last name of inspector
*
First name of inspector
*
Last name of inspector
*
First name of inspector
*
48.
I understand that I am required to complete and submit the Georgia Citizenship Affidavit and provide a copy of an acceptable ID before this application can be reviewed or processed. I further understand that I must use required form GID276-EN, a copy of which is available on the Georgia OCI website. I have completed the form including the required notary and ID and have the scanned copy ready to attach to this application or upload into the NIPR Warehouse immediately upon submission of this application. *
Yes
No
49.
Is the applicant an employee of a Bank or Financial Institution? *
Yes
No
50.
Is the applicant a stockholder, member, associate, director, officer, representative or employee of another producer authorized to do business or doing business in Puerto Rico? Does the applicant have any economic or financial interest or contractual relationship pursuant to the Insurance field with a producer authorized to do business or doing business in Puerto Rico? If the applicant license type is an Authorized Person license, the question does not refer to the business entity that the applicant is currently affiliated to. *
Yes
No
51.
Is the applicant a member of the United States Armed Forces (includes Reserve and National Guard)? *
Yes
No
52.
Is the applicant employed or contracted by the Government of Puerto Rico, U.S. Government, or any of its dependencies, entities, corporations, authorities or by any Municipality, public or private school? *
Yes
No
53.
Is the applicant or the applicant's spouse currently a member of the United States Armed Forces in good standing or have been honorably discharged from service? *
Yes
No
54.
Read the following Certification and Attestation very carefully: 1) I hereby certify that, under penalty of perjury, all of the information submitted in this application is true and complete. I am aware that submitting false information or omitting pertinent or material information in connection with this application is grounds for license revocation or denial of the license and may subject me to civil or criminal penalties. 2) Unless provided otherwise by law or regulation of the jurisdiction, I hereby designate the Commissioner, Director or Superintendent of Insurance, or other appropriate party in each jurisdiction for which this application is made to be my agent for service of process regarding all insurance matters in the respective jurisdiction and agree that service upon the Commissioner, Director or Superintendent of Insurance, or other appropriate party of that jurisdiction is of the same legal force and validity as personal service upon myself. 3) I further certify that I grant permission to the Commissioner, Director of Superintendent of Insurance, or other appropriate party in each jurisdiction for which this application is made to verify information with any federal, state or local government agency, current or former employer, or insurance company. 4) I further certify that, under penalty of perjury, either a) I have no child-support obligation, or b) I have a child-support obligation and I am currently in compliance with that obligation, or c) I have identified my child support obligation arrearage on this application. 5) I authorize the jurisdiction to which this application is made to give any information concerning me, as permitted by law, to any federal, state or municipal agency, or any other organization and I release the jurisdiction and any person acting on their behalf from any and all liability of whatever nature by reason of furnishing such information. 6) I acknowledge that I am familiar with the insurance laws and regulations of the jurisdictions to which I am applying for licensure. 7) For Non-Resident License Applications, I certify that I am licensed and in good standing in my home state/resident state for the lines of authority requested from the non-resident state. 8) I hereby certify that upon request, I will furnish the jurisdiction(s) to which I am applying, certified copies of any documents attached to this application or requested by the jurisdiction(s). *
Agree
Do Not Agree
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