For Department Use Onl
y
License#:
Effective Date:
WS #: ______
Passed Exam Date: _________
State of
California
Bail
Application
For Insurance
License
(Type or print
clearly)
Attach two recent 1 ¼” x 1 ¼”
Passport-Type Photographs
READ THE INSTRUCTIONS ON PAGE 7 BEFORE COMPLETING THIS APPLICATION.
1.
License type:
(check the type [s] for which you are applying.):
Bail Permittee (BP)
Bail Agent (BA) Bail Solicitor (BS)
2. Identification information: Hei
g
ht: Wei
g
ht:
Social Security
Number (SSN)* -
- Hair Color: Eye Color:
3. Last Name First Name Full Middle Name Suffix 4. Male
Female
5. Date of Birth (month/day/year)
6.
Resident Address (P.O. Box not acceptable) 7. City 8. State 9. Zip Code
10. Home Phone
Number
(
) -
11. Are you a citizen of the United States? (check one) Yes
No
(If No, you must supply a copy of both sides of your work authoriz
ation)
12. Business
A
ddress
(
P.O. Box not acceptable.
)
13. Cit
y
14. State 15. Zip Code
16. Business Phone
Number
(
) -
17. Cellular Phone
Number
(
) -
18. E-mail Address (Required) 19. Business Web Site Address
20. Mailing Address (P. O. Box is acceptable) 21. City 22. State 23. Zip Code
24. Special Accommodation Requests for Examination: If required, arrangements were to be made prior to taking and passing the licen
se
examination.
25. PERSONAL HISTORY
(A) Account for
all time for the past five years. Give all employment experiences starting with your current employer working back five years. In
clude
full and part-time work, self-employment, military
service, unemployment, and full-time education. Attach separate sheet, if n
eeded.
From
Month
Year
To
Month Year
Position Held
Name
City State
Name
City State
Name
City State
(B) If currently e
mployed, will you continue this occupation after receiving the license for which this application is b
eing made? Yes No
26. Do you now hold, or have you ever held any license/permit under which you engaged in any occupation? Yes No
Type of License State or Province Date License Held Is License in Force?
*Mandatory pursuant to Cal. Ins. Code, § 1666.5; Cal. Civil Code, § 1798.17; Cal. Family Code, § 17520(d); and Federal Privacy Ac
t of 1974,
§§7(a)(2)(B) and 7(b).
Page 1 o
f 7
LIC 431-1 (2/2014)
27. AKA/ALIAS
Are you now using or have you ever used any name other than shown?
If yes, list names, dates and reason(s) used:
Yes No
Last First
Middle Suffix Dates Used
Reason Used
Last First
Middle Suffix Dates Used
Reason Used
28.
FICTITIOUS
NAMES:
Do you intend to use a fictitious (DBA) name to conduct your bail business?
If YES, list the name: (This name must be approved by the Department prior to use.)
Yes No
29.
BAIL AGENT APPLICANTS ON
LY:
(A) Will undertaking of bail be supplied to you through a general agent or other intermediaries?
If you answer YES, give the na
me of such person:
(B) Will you or anyo
ne else make a deposit of money or thing of value to establish an initial reserve a
ccount for you?
If you answer YES, complete the following:
Describe the type of deposit (i.e., cash, securities, real property, etc.)
What is the value thereof?
With whom will such deposit be made?
By whom will such deposit be made?
Yes No
Yes No
30. Bail a
g
ent and
/
or permittee applicants onl
y
:
Will any person, other than you, receive any income or remuneration from your bail business? (Exclude your employees,
your employing bail agents/permittee, your general agent and the appointing surety.)
Yes No
Name
Resident Add
r
ess Interest or Affiliation
Last First Middle
Page 2 of 7
LIC 431-1 (2/2014)
31. Bail permitee applicant onl
y
:
Attach a detailed
current financial statement listing the dollar amount of each of your assets, liabilities, and net worth, (i.e.,
personal property, real estate, savings, household furnishings, etc.).
If applicant or applicant’s employer is a partnership, complete the following: (Attach a separate sheet if more space is needed.)
(A)
Partne
rship name:
(B) Partners’ Names Bail License Nu
mber
If not licensed, list their
functions/responsibilities within
the partnership.
32.
If you answer yes to any of the following questions, attach a supplementary statement giving complete details with an origina
l
signa
tu
re:
A
.
A
re
y
ou now or have
y
ou ever been connected with a law enforcement a
g
enc
y
? Yes No
B.
Have you ever been named as a defendant in a civil su
it? Yes
No
C. Have
y
ou ever filed bankruptc
y
? Yes No
Notice: Information Collection and Access
• Section 1798.17 of the California Civil Code requires the following information to be provided when collecting information from individuals to determine
compliance with the group and corporate practice provisions of the law, and to establish positive identification, to match the names of the certified list
provided by the Department of Child Support Services to applicants and licensees, and of responding to requests for this information made by child
support agencies.
• Agency: Department of Insurance, Address: 300 Capitol Mall, 16th Floor, Sacramento, CA 95814-4313, Telephone Number: (800) 967-9331.
• Title of official responsible for information maintenance: Chief, Producer Licensing Bureau.
• Authority which authorizes the maintenance of the information: California Insurance Code, Chapters 5, 6, 7, 8-Part 2, Division 1.
• The consequences, if any, of not providing all or part of the requested information: It is mandatory that you provide all information requested.
Omission of any item of requested information will result in the application being rejected as incomplete.
• The principal purpose(s) for which the information is to be used: The information requested will be used to determine qualifications for licensure or
certification, to determine compliance with the group and corporate practice provisions of the law and to establish positive identification.
• Each individual has the right to review files maintained on them by the agency, unless information is classified as confidential under section 1798.3(a)
of the Civil Code.
Page 3 of 7
LIC 431-1 (2/2014)
Background Information
If you fail to fully disclose any in
formation that is requested or if you make a false statement, your application may be denied.
33. 1. Have you ever been convicted of
a felony?
Yes No
For the purpose of this application, you have be en “convicted” if you were ever found guilty b y verdict of a judge o
r
jury; and/or ever entered a
plea of guilty , nolo contendere or no contest. You m ust disclose all convictions, e ven if
the charges were later dismisse
d or expunged, your guilt y ple a was withdrawn pursuant to Penal Code Section
1203.4, or you were placed on probation, received a su spended sentence or just ordered to pay a fine. If you fail t o
disclo
se all convictions, your application may be denied. You may exclude juvenile offenses tried in juvenile
court.
If you answer “Yes” to this BACKG
ROUND question, you must attach to this application:
a)
a written statement, with original signature, explaining the circumstances of each convicti
on or charge; and
b) certified copie
s of the charging documents, and of the court documents which d etail the conviction, resolutio
n
of the charges, probation and any final judgment.
Federal law (18 U.S.C. 1033) p rohibits anyone who has been convicted of a fe lony invo lving d ishonesty or a
breach of trust or who has bee n convicted of a ny vi olation of 1 8 U.S.C. 1033 and 1034 from conducting the
business of insurance unless th ey have obtaine d the wr itten consent of the Insurance Commissioner. It is a
violation of this statute to conduct business of i nsurance without the Commissioner’s written consent. If you
have been convicted of a felony involving dishon esty or a breach of trust or a vio lation 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?
Yes No
2b. If “Yes”, have you received consent from the California Insurance Commissioner?
Yes No
For the purpose of this 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 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 you answered “Yes” to BACKGROUND question 2a, you must attach to this application:
Yes No
a) a written statement, with original signature, explaining the circumstances of each conviction or charge; and
b)
certified copies of the chargin
g documents, and of the court documents which detail the convicti
on, resolution
of the charges, probation and any final judgmen
t
3.
Have you ever been convicte
d of a misdemeanor?
Yes No
For the purpose
of this application, you have be
en “convicted” if you were ever found guilty b y verdict of a judge or
jury; and/or ever entered a
plea
of guilty , nolo contendere or no contest. You
m ust disclose all convictions, e ven if
the charges were later dismissed or expunged, your guilt
y ple a was withdrawn pursuant to Penal Code Section
1203.4, or you were placed on probation, received a su spended
sentence or just ordered to pay a fine. If you fail t o
disclose all convictions, your application may be
denied. You may exclude juvenile offenses tried in juvenile court.
If you answer “Yes” to this 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 convicti
on, resolution
of the charges, probation and any final judgment.
Page 4 o
f 7
LIC 431-1 (2/2014)
Back
g
round Information
If you fail to fully disclose any information that is requested or if you make a false statement, your application may be denied.
Yes No
4. Have you ever been convicted of a military offense?
For the
purpose of this application, you have been “convicted” if you were ever f ound guilty by verdict of a judge or jury; and /or
ever entered a plea of guilty , nolo contendere or no contest. You must disclose al l 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 susp ended sentence or just ordered to pay a fine. If y ou fail to disclose all convict ions, your application may be
denied. You may exclude juvenile offenses tried in juvenile court.
If you answer “Yes” to this 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 cour t documents which detail the co nviction, resolut ion of the
charges, probation and any final judgment.
5. Are you currently charged with committing a crime?
Yes
No
“Crime” includes a felony, a mis demeanor or a military offense. You may exclude traffic citations but should include dr
iving
offenses such a
s, but not limited to, reckless driving, driving under the influence and driving with a suspended licen
se.
If you answer “Yes” to this BACKG
ROUND question, you must att
ach to this application:
a)
a written state
ment, with original signature, explaining the circu
mstances of each charge; and
b) certified copies of the charging documents.
6.
Have you ever been involved
in an administrative proceeding (including matters with the Depart ment of Insurance) regarding an
y
professional or occupational
licen
se?
Yes
No
For the purpose of this application, “Involved” means having a license censured, suspended, revoked, cancelled, te
rminated; or
being assessed a fine, placed on probation or surrendering a license to resolve an administrative action. “Involved” also means
being named 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 denial.
You may
exclude terminat
ions due solely to noncompliance with continuing
education requirements or failure to pay a renewal fee.
If you answer “Yes” to this BACKGROUND question, you must attach to this application:
a)
a written state
ment, with original signature, explaining the circumstances of each disciplinary in
cident; and
b) certified copies of the Notice o
f Hearing or other document that states the charges and allegatio
ns, and of the document
which demonstrates the resolution of the charges or any final judgment.
7.
Has any busine
ss in which you are or we re a n owner, pa rtner, officer or dire ctor ever been involved in an adminis
trative
proceeding (including matters with the Departme
nt of Insurance) regarding any professional or occupational licens
e?
Yes No
For the purpose of this application, “Involved” means having a license censured, suspended, revoked, cancelled, te
rminated; or
being assessed
a fine, placed on probation or surrendering a license to resolve an administrative action. “Involved” also mean
s
being named 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 denial.
You may
exclude terminat
ions due solely to noncompliance with continuing
education requirements or failure to pay a renewal fee.
If you answer “Yes” to this BACKG
ROUND question, you must att
ach to this application:
a) a written stat
ement, with original signature, explaining the circumstances of each disciplinary in
cident; and
b)
certified copies of the Notice o
f Hearing or other document that states the charges and allegatio
ns, and of the document
which demonstrates the resolution of the charges or any final judgment
8.
Has any deman
d been made or judgment rendered against you for any overdue monies by any insurer, insured or producer, o
r
have you ever b
een subject to a bankruptcy proceeding? (only include bankruptcies that involve funds held on be
half of others)
Yes
No
If you answer yes, submit a statement, with an original signature, summarizing the details of the indebtedness and
arrangements
for repayment, a
nd/or type and location of bankru
ptcy.
If you answer yes, identify the
jurisdiction(s):
Page 5 of 7
LIC 431-1 (2/2014)
Back
g
round Information
If you fail to fully disclose any information that is requested or if you make a false statement, your application may be denied.
Yes
No
repayment agreement
?
9.
Have you ever been notified by any jurisd
iction of any delinquent tax obligation that is not the
subject of a
10.
Are you currently a party to or have you ever been found liable in any lawsuit or arbitration proceeding involving allegations of
Yes No
fraud, misappropriation or conversion of funds, mi
srepresentation or breach of fiduciary duty?
If you answer “Yes”, you must attach to this application:
a) a written state
ment, with original signature, summarizing the details of each
incident; and
b) a copy of the Petition, Compla
int, or other docum
ent 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
11.
Have you o
r any business in which you are or were an owner, partner, officer o r director ever ha d an insurance agency contr act
Yes No
or any other business relationship with an insurance company terminated for any alleged miscond
uct?
If you answer “Yes”, you must attach to this application:
a) a written state
ment, with original signature, summarizing the details of each incident and explaining why you fe
el this
incident shou
ld not prevent you from
receiving an insurance license; and,
b) copies of any relevant documents.
34. Applica
nt’s Certification:
I declare that I have read Sections 2053 through 2104 of Title 10 of the California Code of Regulations.
I represent that the
holding of the license hereby applied for is not in
compatible with the laws, rules or regulations of any federal, state, or mun
icipal
government
by which I am currently employed (if any) or by which my employer or I am licensed If
any).
I certify under penalty of perjury that I have read the forgoing application and know the contents thereof and that each statement
herein made is full, true, and correct and I agree
to notify the Insurance Commissioner of any change in the matters set forth
in
this application.
I understand that pursuant to Sections 1668(h) and 1738 of the Califor
nia Insurance Code any false statement may subject m
y
application to de
nial and may subject my license(s) to suspension or revocation. Further, pursuant to insurance co
de sections
1703 and 1733, I authorize disclosure to the insu
rance commissioner of all financial institution records of any fiduciary accou
nts
for the duration of this license
All fees are filing
fees and are not refundable, whether or not the application is acted upon or an examination taken per section 1751.5
of the CIC.
35.
Applicant’s signature: City Date
Section 31(e) of the California Business and Professional Code allows the State Board of Equalization and the Franchise Tax Board to share taxpayer
information and requires the licensee to pay his or her state tax obligation. Section 31 also states that the license may be suspended if the state tax obligation
is not paid.
Page 6 of 7
LIC 431-1 (2/2014)
REQUIREMENTS, CHECKLIST AND INFORMATION FOR COMPLETING APPLICATION
Requirements:
Bond coverage is required for all bail licenses.
Fingerprint impressions are required for all unlicensed applicants.
Forms Filing List: Each bail agent or permitee applying for a license must provide a copy of the forms or documents which the licensee intends to
use regularly or frequently in connection with his/her bail transactions (Section 2095(k) of the California Code of Regulations). Bail agent applicants
can comply with Section 2095(k) by submitting a Forms Filing List. Applicants must obtain the Forms Filing List from your surety company as the list
is not available through CDI. This signed Forms Filing List must accompany this application. NOTE: Bail solicitors are exempt from this requirement
since they will utilize their employer’s forms when transacting bail.
A Bail Agent Action Notice (Form LIC 437-23) from a surety company is required for a bail agent applicant. A separate filing fee is required for each
subsequent appointment submitted with the application.
An Action Notice Statement of Employing Bail Agent or Permitee (Form LIC 438) from a bail agent or permitee is required for a bail solicitor
applicant. If a bail solicitor applicant is going to work for two or more bail licensees who are members of a partnership, a separate Action Notice
statement from each employer and an additional filing fee for each is required.
An Action Notice Statement of Employing Bail Agent or Permitee (Form LIC 438) from a bail agent or bail permitee is required when employing or
terminating the employment of another licensed Bail Agent or Permitee.
All fictitious names must be approved by the CDI prior to use. Refer to Section 2066.4 of the California Code of Regulations (CCR) for fictitious name
filing requirements. If applying for a bail permittee’s license, also refer to Section 2094 and 2094.5 of the CCR.
A computer-based examination administered by the CDI or its examination vendor is required if examination qualifications have not already been met.
Checklist:
All entries, except signature, must be typed or printed clearly.
Application must be completed in full, signed, dated and accompanied by all required fees and supplemental documents (forms filing list and, form
LIC 437-23. Form LIC 438 if applying as a bail solicitor). Incomplete filings will require an amendment and result in delays processing the application.
A bail agent’s and permittee’s license may be applied for at the same time by checking both appropriate boxes of section “1” on the application, in
which case, only a permittee’s bond is required. Also, if a currently licensed bail permitee is now applying for an agent’s license, the permittee’s bond
on file will cover both licenses.
Information:
Prelicensing Education Requirement: Effective January 1, 2012 all new applicants must complete a minimum of 20 hours of approved classroo
m
study.
The computer-b
ased examination administered by the CDI and its examination vendor consists of 75 questions based on educational objectives th
at
can be downloaded at CDI’s web site. Go to www.insurance.ca.gov and type “educational objectives” in the search box. Click on educational
objective
s and select “bail”. The education providers use the CDI educational objectives to develop their prelicensing courses
.
The CDI does n
ot recommend any specific school, course or method of training to prepare for the bail examination
.
An applicant for license may not
solicit, negotiate or transact bail until authorized to do so under an appropriate license issued by the
CDI.
A false statemen
t on the background questions will delay your application and may result in its den
ial.
You will receive an email at the address provided in this application when your license is issued.
Your bail identifi
cation card will be mailed to you after your license is issued. This may take at least five business days to
arrive at the mailing
address listed o
n this application
.
Mail appli
cation, filing fees and required forms to: California Department of Insurance
P.O. Box 1139
Sacramento, CA 95812-1139
ALL FEES
ARE FILING FEES AND ARE NOT REFUNDABLE, WHETHER OR NOT THE APPLICATION IS ACTED UPON OR THE EXAMINATION IS
TAKEN PER SECTION 1751.5 OF THE CALIFORNIA INSURANCE CODE.
Page 7 of 7
LIC 4
31-1 (1/2023)
