State of California Department of Insurance

Individual Application For Insurance License

LIC-441-9 (Rev 08/2019)

1. Application Type: Permanent Certificate of Convenience For Department Use Only License #

2. License Type:

Accident and Health Agent (AH)

Life-Only Agent (LO)

Variable Contract Authority (VC)

Property Broker-Agent (PR)

Casualty Broker-Agent (CA)

Personal Lines Broker-Agent (PL)

Limited Lines Auto Insurance Agent (AU)

Credit Insurance Agent (CI)

Part Time Fraternal Agent (PF)

Portable Electronics Agent (PE)

Rental Car Agent (RC)

Surplus Line Broker (SL)*

Special LineV SXrplXV Line Broker (SP)*

Self-Service Storage Agent (SS)

Title Marketing (TM)

Burial and Funeral Expenses (LOLP)

Life & Disability Analyst (LA)

Motor Club Agent (MC)

Cargo Shipper V AgenW (CS)

Vehicle Service Contract

Provider (VS)

3. Last Name First Name Middle Name Suffix

4. Male Female 5. Birthdate (MM/DD/YYYY) 6. Social Security Number or Individual Tax Identification Number** 7. Resident Address (P.O. Box not acceptable) 8. City 9. State 10. Zip Code 11. Home Phone Number 12. Are you a citizen of the United States? Yes No 13. Are you affiliated with a financial institution/bank?

Yes No

14. Business Address (P.O. Box not acceptable.) 15. City 16. State 17. Zip Code 18. Business Phone Number 19. Business Fax Number 20. E-mail Address (required) 21. Business Web Site Address 22. Mailing Address (P.O. Box is acceptable.) 23. City 24. State 25. Zip Code 26. Special Accommodation Request for Examination - If required, arrangements were made prior to taking and passing the license examination.

27. Examination Information: If required, you must first pass your license examination before submitting this license application. After you pass your license examination, please ensure that all required documents are submitted. If you are required to submit documents, please email them to: adrnwq@r.postjobfree.com or send them to: CA Dept. of Insurance, Attention: Individual License Application, 320 Capitol Mall, Sacramento, CA 95814-4309

*Form LIC 050 mXVW be compleWed and VXbmiWWed ZiWh SXrplXV and/or Whe Special LineV SXrplXV Broker ApplicaWion.

**Disclosure of your U. S. social security number is mandatory pursuant to; Cal. Family Code, § 17520(d); the Federal Tax Reform Act of 1976 (42 U.S.C. §405(c)(2)(C)(i)) and the Federal Welfare Reform Act of 1996 (42 U.S.C. §666). If you fail to disclose your social security number or your individual tax identification number, your application will not be reviewed. An individual has a right of access to certain records containing personal information pertaining to that individual. Individuals may obtain information regarding the location of their records by contacting the Bureau Chief, Producer Licensing Bureau, California Department of Insurance by telephone 800-***-****) or by mail to the following address: 320 Capitol Mall, Sacramento CA 95814. Or an Individual Tax Identification Number issued by the Internal Revenue Service pursuant to Cal. Insurance Code,

§1666.5(a)(2).

Solution#

adrnwq@r.postjobfree.com

ca 91761

800-***-**** 800-***-**** www.primerica.com

2171 S. Grove Ave. Suite K ontario ca 91761

2171 S. Grove Ave. Suite K ontario

877-***-**** 877-***-**** adrnwq@r.postjobfree.com Hernandez BRYAN aXEL

01/23/2020 ***-**-****

2850 mission inn avenue riverside ca 92507

951-***-****

769TT

Text

Page 2 of 6 LIC 441-9 (Rev. 08/19)

28. Work/Personal History: Account for all time for the past five years. Give all employment experiences starting with your current employer working back five years. Include full and part-time work, self-employment, military service, unemployment, and full-time education. Attach separate sheet, if needed. From

Month Year

To

Month Year Position Held

Name

City State

Name

City State

Name

City State

Name

City State

29. Do you now hold, or have you ever held, an insurance license as a resident in this state or any other state? Yes No

Type of License State or Province Date License Held Is License in Force? 30. AKA/Alias

Are you now using or have you ever used any name other than shown? Yes No If yes, list names, dates and reason(s) used:

Last First Middle Suffix Dates Used Reason Used

Last First Middle Suffix Dates Used Reason Used

31. Fictitious Names:

Do you intend to use a fictitious (DBA) name?

If yes, list the name: (This name must be approved by the Department prior to use) Yes No 32. Life-Only Agent/Part Time Fraternal License Applicants Only: Are you registered with SECO or FINRA? Yes No

Central Registration Depository Number (CRD) If CRD# is not provided, acceptable proof of registration must be attached before the authority may be granted. If acceptable proof is not submitted, license will be issued without Variable Contract authority.

33. Prelicensing Certificates:

Do you certify that you have completed your prelicensing education? Yes No If no, your prelicensing education must be completed prior to taking your examination. If yes, you must provide the completion date:

John w north high school

riverside ca

jan 2015 may2020 student

may 2020 present

unemployed

unemployed

riverside ca

8/31/2020

Page 3 of 6 LIC 441-9 (Rev. 08/19)

34. Background Information

If you fail to fully disclose any information that is requested or if you make a false statement, your application may be denied. 1. Have you ever been convicted of a felony?

For Whe pXrpoVe of WhiV applicaWion, \oX haYe been conYicWed if \oX Zere eYer foXnd gXilW\ b\ YerdicW of a judge or jury; and/or ever entered a plea of guilty, nolo contendere 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. If you fail to disclose all convictions, your application may be denied. You may exclude juvenile offenses tried in juvenile court.

If \oX anVZer YeV Wo WhiV background question, you must attach to this application: a) a written statement, with original signature, explaining the circumstances of each conviction or charge; and,

b) certified copies of the charging documents, and of the court documents which detail the conviction, resolution of the charges, probation and any final judgment. Yes No

2 . Federal law (18 U.S.C. 1033) prohibits anyone who has been convicted of a felony involving dishonesty or a breach of trust or who has been convicted of any violation of 18 U.S.C. 1033 and 1034 from conducting the business of insurance unless they have obtained the written consent of the Insurance Commissioner. It is a YiolaWion of WhiV VWaWXWe Wo condXcW bXVineVV of inVXrance ZiWhoXW Whe CommiVVioner V ZriWWen conVenW. If \oX have been convicted of a felony involving dishonesty or a breach of trust or a violation of 18 U.S.C. 1033 and 1034, then you must attach a copy of this consent. If you have not obtained this written consent you must do so prior to filing your application.

2a. Have you ever been convicted of a felony involving dishonesty or a breach of trust? 2b. If YeV, haYe \oX receiYed conVenW from Whe California Insurance Commissioner? For Whe pXrpoVe of WhiV applicaWion, \oX haYe been conYicWed if \oX Zere eYer foXnd gXilW\ b\ YerdicW of a judge or jury; and/or ever entered a plea of guilty, nolo contendere 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. If you fail to disclose all convictions, your application may be denied. You may exclude juvenile offenses tried in juvenile court.

If \oX anVZered YeV Wo background question 2a, you must attach to this application: a) a written statement, with original signature, explaining the circumstances of each conviction or charge; and,

b) certified copies of the charging documents, and of the court documents which detail the conviction, resolution of the charges, probation and any final judgment. Yes

Yes

No

No

3. Have you ever been convicted of a misdemeanor?

For Whe pXrpoVe of WhiV applicaWion, \oX haYe been conYicWed if \oX Zere eYer foXnd gXilW\ b\ YerdicW of a judge or jury; and/or ever entered a plea of guilty, nolo contendere 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. If you fail to disclose all convictions, your application may be denied. You may exclude juvenile offenses tried in juvenile court.

If \oX anVZer YeV Wo WhiV background question, you must attach to this application: a) a written statement, with original signature, explaining the circumstances of each conviction or charge; and,

b) certified copies of the charging documents, and of the court documents which detail the conviction, resolution of the charges, probation and any final judgment. Yes No

Page 4 of 6 LIC 441-9 (Rev. 08/19)

8

34. Background Information continued.

If you fail to fully disclose any information that is requested or if you make a false statement, your application may be denied. 4. Have you ever been convicted of a military offense? For the purpose of this applicaWion, \oX haYe been conYicWed if \oX Zere eYer foXnd gXilW\ b\ YerdicW of a judge or jury; and/or ever entered a plea of guilty, nolo contendere or no contest. You must disclose all convictions, even if the charges were later dismissed or expunged, or you were placed on probation, received a suspended sentence or just ordered to pay a fine. If you fail to disclose all convictions, your application may be denied. You may exclude juvenile offenses tried in juvenile court. If \oX anVZer YeV Wo WhiV background question, you must attach to this application: a) a written statement, with original signature, explaining the circumstances of each conviction or charge; and, b) certified copies of the charging documents, and of the court documents which detail the conviction, resolution of the charges, probation and any final judgment. Yes No

5. Are you currently charged with committing a crime?

Crime inclXdeV a felon\, a miVdemeanor or a miliWar\ offenVe. YoX ma\ e[clXde Wraffic ciWaWionV bXW should include driving offenses such as, but not limited to, reckless driving, driving under the influence and driving with a suspended license.

If \oX anVZer YeV Wo WhiV background question, you must attach to this application: a) a written statement, with original signature, explaining the circumstances of each charge; and, b) certified copies of the charging documents.

Yes No

6. Have you ever been involved in an administrative proceeding (including matters with the Department of Insurance) regarding any professional or occupational license? For Whe pXrpoVe of WhiV applicaWion, InYolYed meanV haYing a licenVe cenVXred, VXVpended, reYoked, cancelled, terminated; or being assessed a fine, placed on probation or surrendering a license to resolve an adminiVWraWiYe acWion. InYolYed alVo meanV being named a parW\ Wo an adminiVWraWiYe or arbiWraWion proceeding Zhich iV relaWed Wo a profeVVional or occXpaWional licenVe. InYolYed alVo meanV haYing a licenVe application denied or the act of withdrawing an application to avoid denial. You may exclude terminations due solely to noncompliance with continuing education requirements or failure to pay a renewal fee. If \oX anVZer YeV Wo WhiV background question, you must attach to this application: a) a written statement, with original signature, explaining the circumstances of each disciplinary incident; and, b) certified copies of the Notice of Hearing or other document that states the charges and allegations; and, of the document which demonstrates the resolution of the charges or any final judgment. Yes

No

7. Has any business in which you are or were an owner, partner, officer or director ever been involved in an administrative proceeding (including matters with the Department of Insurance) regarding any professional or occupational license?

For Whe pXrpoVe of WhiV applicaWion, InYolYed meanV haYing a licenVe cenVXred, VXVpended, reYoked, cancelled, terminated; or being assessed a fine, placed on probation or surrendering a license to resolve an adminiVWraWiYe acWion. InYolYed alVo meanV being named a parW\ Wo an adminiVWraWiYe or arbiWraWion proceeding Zhich iV relaWed Wo a profeVVional or occXpaWional licenVe. InYolYed alVo meanV haYing a licenVe application denied or the act of withdrawing an application to avoid denial. You may exclude terminations due solely to noncompliance with continuing education requirements or failure to pay a renewal fee. If \oX anVZer YeV Wo WhiV background question, you must attach to this application: a) a written statement, with original signature, explaining the circumstances of each disciplinary incident; and, b) certified copies of the Notice of Hearing or other document that states the charges and allegations, and of the document which demonstrates the resolution of the charges or any final judgment. ‘ Yes

No

8. Has any demand been made or judgment rendered against you for any overdue monies by any insurer, insured or producer, or have you ever been subject to a bankruptcy proceeding? (Only include bankruptcies that involve funds held on behalf of others). If \oX anVZer YeV, VXbmiW a VWaWemenW, ZiWh an original VignaWXre, VXmmari]ing Whe deWailV of Whe indebtedness and arrangements for repayment, and/or type and location of bankruptcy. Yes

No

Page 5 of 6 LIC 441-9 (Rev. 08/19)

34. Background Information continued.

If you fail to fully disclose any information that is requested or if you make a false statement, your application may be denied. 9. Have you ever been notified by any jurisdiction of any delinquent tax obligation that is not the subject of a repayment agreement?

If \oX anVZer YeV, idenWif\ Whe jurisdiction(s): Yes No

10. Are you currently a party to or have you 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?

If \oX anVZer YeV, \oX mXVW aWWach Wo this application: a) a written statement, with original signature, summarizing the details of each incident; b) copy of the Petition, Complaint, or other document that commenced the lawsuit or arbitration; and c) a copy of the official document which demonstrates the resolution of the charges or any final judgment. Yes No

11. Have you or any business in which you are or were an 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?

If \oX anVZer YeV, \oX mXVW aWWach Wo WhiV applicaWion: a) a written statement, with original signature, summarizing the details of each incident and explaining why you feel this incident should not prevent you from receiving an insurance license; and, b) copies of any relevant documents.

Yes No

35. Applicant s Certification:

By submitting this electronic application I certify under penalty of perjury that I have read the foregoing application and know the contents thereof and that each statement therein made is full, true and correct. I understand that pursuant to sections 1668(h) and 1738 of the insurance code, any false statement may subject my application to denial and may subject my license(s) to suspension or revocation. Further, pursuant to insurance code sections 1703 and 1733, I authorize disclosure to the insurance commissioner of all financial institution records of any fiduciary accounts for the duration of this license. All fees are filing fees and are not refundable, whether the application is acted upon or an examination taken. Applicant s Signature: City Date

CALIFORNIA Exam Language Preference

Please indicate the language you prefer to take your exam in, by checking one of the boxes below.

F ENGLISH F SPANISH

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F CDI TEST SITE F PSI TEST SITE

CDI EXAMINATION SITE LOCATIONS

Fingerprinting is processed by Accurate Biometrics (1-866-***-****) for $58.30. LOS RONALD 300 FIRST SUITE LOS SOUTH ANGELES, ANGELES FLOOR 1000 REAGAN SPRING NORTH CA 90013 BUILDING STREET TOWER PSI EXAMINATION SITE LOCATIONS

Fingerprinting is processed by MorphoTrust USA (1-800-***-****) and is provided at no cost with Primerica Account Number (provided to you by your RVP) or for $68.95. (Please submit copy of receipt with your Pass Notice for reimbursement of fees.) ANAHEIM 2301 ANAHEIM, W LINCOLN CA 92801 AVE, STE 252 ATASCADERO 7305 ATASCADERO, MORRO RD, CA SUITE 93422 201A BAKERSFIELD 5405 BAKERSFIELD, STOCKDALE CA HWY, 93309 STE 206 BURBANK, BURBANK 2950 SUITE N 200 HOLLYWOOD CA 91505 WAY CARSON 17420 CARSON, S AVALON CA 90746 BLVD, STE 205 COLFAX 111 COLFAX, SOUTH CA RAILROAD 95713 STREET

EL 4399 EL MONTE, MONTE SANTA CA ANITA 91731 AVE, STE 110 FRESNO 351 FRESNO, E BARSTOW, CA 93710 SUITE 101

HAYWARD 24301 HAYWARD, SOUTHLAND CA 94545 DR, STE B-1 LANCASTER FOX 4555 LANCASTER, FIELD WEST AVENUE CA 93539 G LIVERMORE LIVERMORE 186 LIVERMORE, AIRWAY AIRPORT CA BOULEVARD 94550 REDDING 2861 REDDING, CHURN CA CREEK, 96002 UNIT C RIVERSIDE 7888 SUITE RIVERSIDE, MISSION 130 CA GROVE 92508 PKWY S SACRAMENTO 9719 SACRAMENTO, LINCOLN VILLAGE CA 95827 DR 8950 SUITE SACRAMENTO, CAL 158 CENTER CA 95826 DRIVE SAN 5440 SAN DIEGO, DIEGO MOREHOUSE CA 92121 DR, STE 3300 SAN SAN 150 SUITE EXECUTIVE FRANCISCO, FRANCISCO 1100 PARK CA 94134 BLVD SANTA 2936 SANTA SCOTT CLARA, CLARA BLVD CA 95054

SANTA 160 SANTA WIKIUP ROSA, ROSA DRIVE, CA 95403 SUITE 105 VENTURA 4245 VENTURA, MARKET CA 93003 ST, SUITE 208 VISALIA 3400 SUITE VISALIA, W D MINERAL CA 93291 KING AVE WALNUT 175 WALNUT LENNON CREEK, CREEK LANE, CA SUITE 95827 203

*LOCATION NEEDLES PENDING

Rev. 1/4/18

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