Maryland Insurance Administration
200 St. Paul Place, Suite 2700, Baltimore MD 21202
Email: producerlicensing.mia@maryland.gov; Fax 410-468-2399; Telephone 410-468-2411
Title Producer Business Entity Application checklist
Initial and Renewal Application
NAIC Uniform Application
Fee - $54 for initial application; $69 for renewal application
$150, 000 Fidelity Bond* or Bond Waiver
$150,000 Surety Bond* or Letter of Credit
*The Fidelity and Surety bond or continuation certificate must clearly state:
- bond company and bond amount
- bond coverage period
- show the State of Maryland as the obligee
- duly executed by the principal/producer and bond company/attorney-in-
fact
Renewal applications: submit the Update to Owners, Partners, Officers,
Directors, Members form. (List the individual names and corresponding
offices. “No changes” is not an acceptable response.)
Please note the application may be revised on a bi-annual basis. To ensure you are filing the current version of the application, please
reference the National Insurance Producer Registry web site at www.nipr.com.
© 2014 National Association of Insurance Commissioners
Page 1 of 8
Uniform Application for
Business Entity License/Registration
(Please Print or Type)
Check appropriate boxes for license requested.
Resident License
Non-Resident License
o Identify Home State:_______________
o Identify Home State License #:_____________
New Application
Additional Line(s) of Authority
(State Use)
Demographic Information
Business Entity Name Incorporation/Formation Date
(month) ___(day) ___(year) _____
FEIN
-
If assigned, National Producer Number (NPN) If applicable, FINRA Firm Central Registration Depository (CRD)
List any other assumed, fictitious, alias or trade names under which you are currently
doing business or intend to do business.
State of Domicile Country of Domicile
Is the business entity affiliated with a financial institution/bank? Yes No
Business Address City State Zip Code Foreign Country
Phone Number (include Ext.)
( ) -
Fax Number
( ) -
Business Web Site Address Business E-Mail Address
Mailing Address P.O. Box City State Zip Code Foreign Country
Designated/Responsible Licensed Producer
Identify at least one Designated/Responsible Licensed Producer responsible for the business entity’s compliance with the insurance laws, rules and regulations of this
state. (See Matrix of State Requirements at www.nipr.com for jurisdictions that require the designated/responsible licensed producer to be an officer, director or partner
of the business entity.)
Name
SSN
- - NPN _______________________
Name
SSN
- - NPN________________________
Name
SSN
- - NPN________________________
Name
SSN
- - NPN________________________
Owners, Partners, Officers and Directors
Identify all owners with 10% interest or voting interest, partners, officers and directors of the business entity, or members or managers of a limited liability company:
Name Title SSN/FEIN - - D.O.B ___________Owner: Yes / No % of ownership interest ____
Name Title SSN/FEIN - - D.O.B ___________Owner: Yes / No % of ownership interest ____
Name Title SSN/FEIN - - D.O.B ___________Owner: Yes / No % of ownership interest ____
Name Title SSN/FEIN - - D.O.B ___________Owner: Yes / No % of ownership interest ____
Name Title SSN/FEIN - - D.O.B ___________Owner: Yes / No % of ownership interest ____
Name Title SSN/FEIN - - D.O.B ___________Owner: Yes / No % of ownership interest ____
Name Title SSN/FEIN - - D.O.B ___________Owner: Yes / No % of ownership interest ____
Name Title SSN/FEIN - - D.O.B ___________Owner: Yes / No % of ownership interest ____
1
3
15 16 17
18
26
25
6
7
8
4
5
9
11 12 1410
2
13
19 20
21
22
23
24
Please note the application may be revised on a bi-annual basis. To ensure you are filing the current version of the application, please
reference the National Insurance Producer Registry web site at www.nipr.com.
Uniform Application for
Business Entity License/Registration
Applicant Name:______________________________________
© 2014 National Association of Insurance Commissioners
Page 2 of 8
Back
g
round
Q
uestions
Please read the following very carefully and answer every question. All written statements submitted by the Applicant must include an
original signature.
1a. Has the business entity or any owner, partner, officer or director of the business entity, or member or manager of a limited liability
company, ever been convicted of a misdemeanor, had a judgment withheld or deferred or is the business entity or any owner, partner,
officer or director
of the business entity, or member or manager currently charged with, committing a misdemeanor? Yes ___ No___
You m
ay exclude the following misdemeanor convictions or pending misdemeanor charges: traffic citations, driving under the influence
(DUI) or driving while intoxicated (DWI), driving without a license, reckless driving, or driving with a suspended or revoked license.
You may also exclude juvenile adjudications (offenses where you were adjudicated delinquent in juvenile court.)
1b. Has the business entity or any owner, partner, officer or director of the business entity,
or member or manager of a limited liability
company ever been convicted of a felony, had judgment withheld or deferred, or is the business entity or any owner, partner, officer or
director of the business entity or member or manager of a limited liability company currently charged with committing a felony?
You may exclude juvenile adjudications (offenses where you were adjudicated delinquent in a juvenile court.)
If you have a felony conviction involving dishonesty or breach of trust, have you applied for written consent to engage in the business of
insurance in your home state as required by 18 USC 1033?
If so, was consent granted? (Attach copy of 1033 consent approved by home state.)
1c. Has the business entity or any owner, partner, officer or director of the business entity
or member or manager of a limited liability
company, ever been convicted of a military offense, had a judgment withheld or deferred, or is the business entity or any owner, partner,
officer or director of the business entity
or member or manager of a limited liability company, currently charged with committing a
military offense?
Yes ___ No___
N/A___ Yes____ No____
N/A___ Yes ____ No____
Yes ___ No___
NOTE: For Questions 1a, 1b, and 1c “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.
If you answer yes to any of these questions, you must attach to this application:
a) a written statement identifying all parties involved (including their percentage of ownership, if any)
and explaining the
circumstances of each incident,
b) a copy of the charging document,
c) a copy of the official document which demonstrates the resolution of the charges or any final judgme
nt.
2. Has the business entity or any owner, partner, officer or director of the business entity, or manager or member of a limited liability
company, ever been named or involved as a party in an administrative proceeding, including a FINRA sanction or arbitration proc
eeding
regarding any professional or occupational license, or registration? 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, 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 application denied or the act of withdrawing an a
pplication
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, all parties involved (including their percentage of ownership, if any) and
explaining the circumstances of each incident,
b) a copy of the Notice of Hearing or other document that states the charges and allegations, and
c) a 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 of the business
entity, or member or manager of a limited liability company, for overdue monies by an insurer, insured or producer, or have you ever
been subject to a bankruptcy proceeding? Do not include personal bankruptcies, unless they involve funds held on behalf of others. 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 of the business entity, or member or manager of a limited liability
company, 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): _______________________________________
29
Please note the application may be revised on a bi-annual basis. To ensure you are filing the current version of the application, please
reference the National Insurance Producer Registry web site at www.nipr.com.
Uniform Application for
Business Entity License/Registration
Applicant Name:______________________________________
© 2014 National Association of Insurance Commissioners
Page 3 of 8
5. Is the business entity or any owner, partner, officer or director of the business entity, or member or manager of a limited liability
company, 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 copy of the Petition, Complaint or other document that commenced the lawsuit arbitrations, or mediation proceedings and
c) a copy of the official documents which demonstrates the resolution of the charges or any final judgment.
6. Has the business entity or an
y owner, partner, officer or director of the business entity, 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 all
eged
misconduct?
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) copies of all relevant docum
ents.
7.
In response to a “
yes” answer to one or more of the Background Questions for this application, are you submitting document(s) to the
NAIC/NIPR Attachments Warehouse?
If you answer yes:
Will you be associating (linking) previously filed documents from the NAIC/NIPR Attachments Warehouse to this application?
Note: If you have previously submitted documents to the Attachments Warehouse that are intended to be filed with this application, you
must go to the Attachments Warehouse and associate (link) the supporting document(s) to this application based upon the particular
background question number you have answered yes to on this application. You will receive information in a follow-up page at the end of
the application process, providing a link to the Attachment Warehouse instructions.
Yes ___ No___
Yes ___ No___
Yes ___ No___
Please note the application may be revised on a bi-annual basis. To ensure you are filing the current version of the application, please
reference the National Insurance Producer Registry web site at www.nipr.com.
© 2014 National Association of Insurance Commissioners Page 4 of 8
Uniform Application for
Business Entity License Renewal/Continuation
Applicant Name: ___________________________________
Applicant’s Certification and Attestation
On
behalf of the business entity or limited liability company, the undersigned owner, partner, officer or director of the business entity, or member or manager of a
limited liability company, hereby certifies, under penalty of perjury, that:
1.
All of the information submitted in this application and attachments is true and complete and I am aware that submitting false information or omitting pertinent or
material information in connection with this application is grounds for license or registration revocation and may subject me and the business entity or limited liability
company to civil or criminal penalties.
2.
Unless provided otherwise by law or regulation of the jurisdiction, the business entity or limited liability company hereby designates the Commissioner, Director or
Superintendent of Insurance, or an appropriate representative in each jurisdiction for which this application is made to be its agent for service of process regarding all
insurance matters in the respective jurisdiction and agree that service upon the Commissioner or Director of that jurisdiction is of the same legal force and validity as
personal service upon the business entity.
3.
The business entity or limited liability company grants permission to the Commissioner or Director of Insurance in each jurisdiction for which this application is made
to verify any information supplied with any federal, state or local government agency, current or former employer or insurance company.
4.
Every owner, partner, officer or director of the business entity, or member or manager of a limited liability company, either a) does not have a current child-support
obligation, or b) has a child-support obligation and is currently in compliance with that obligation.
5.
I authorize the jurisdictions to which this application is made to give any information they may have concerning me, as permitted by law, to any federal, state or
municipal agency, or any other organization and I release the jurisdictions 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 understand and comply with the insurance laws and regulations of the jurisdictions to which I am applying for licensure/registration.
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).
9
. I certify that the Designated Responsible Licensed Producer(s) named on this application understands that he/she is responsible for the business entity’s compliance
with the insurance laws, rules and regulation of the State.
Must be signed by an officer, director, or partner of the business
entity, or member or manager of a limited liability company:
____________________________________________
Month/Day/Year
____________________________________________
Signature
_________________________________________________
Typed or Printed Name
_________________________________________________
Title
_________________________________________________
Address
_____________
____________________________________
City
State
Zip
21
Page 5 of 8
Rev. 10/2017
1. TITLE FIDELITY BOND INFORMATION
All applicants applying for the Title line of insurance must submit a copy of the original $150,000 Fidelity bond (see the Maryland Insurance Administration Title
Fidelity Bond Form) with this application. Complete the questions below with your Title Fidelity bond information.
1A. *TITLE FIDELITY BOND
INSURANCE COMPANY NAME:
1B. *TITLE FIDELITY BOND NUMBER:
1C. *TITLE FIDELITY BOND ISSUE DATE (MM-DD-YYYY):
2. TITLE SURETY BOND / LETTER OF CREDIT INFORMATION
All applicants applying for the Title line of insurance must submit 1) a copy of the original $150,000 surety bond (see the Maryland Insurance Administration Title
Surety Bond Form) and a concurrently dated Power of Attorney or 2) a letter of credit (see the Maryland Insurance Administration Letter of Credit Form) with this
application. Complete the questions below with your Title Surety bond information.
2A. *Are you submitting a Letter of Credit instead of a Surety Bond?
If YES, please enter your Letter of Credit information below.
Yes
No
2B. *TITLE SURETY BOND INSURANCE COMPANY/
LETTER OF CREDIT BANK NAME:
2C. *TITLE SURETY BOND/ LETTER OF CREDIT NUMBER:
2D. *TITLE SURETY BOND/ LETTER OF CREDIT ISSUE DATE (MM-DD-YYYY):
3. MARYLAND AFFORDABLE HOUSING TRUST (MAHT) INFORMATION
Yes
No
ADDITIONAL INFORMATION
Page 6 of 8
Rev. 10/2017
MARYLAND INSURANCE ADMINISTRATION TITLE SURETY BOND
Bond Number
KNOW ALL MEN BY THESE PRESENT; THAT
of
State of (hereafter called “Principal”), as Principal has applied to the Insurance Commissioner of the
State of Maryland for a license as Title Producer, said license is required by the Insurance Laws of Maryland to give a bond in the penalty
below and conditioned hereinafter set forth; and
with its principal office located at
a corporation authorized to do surety business in the state of Maryland (hereinafter called “Surety”) as Surety, ARE HELD AND FIRMLY
BOUND unto the State of Maryland as Obligee, and any unknown third party, in full and just sum of $150,000 (ONE HUNDRED FIFTY
THOUSAND DOLLARS) to the payment of which well and truly to be made the Principal and Surety hereby bind themselves, their heirs,
executors, administrators, successors and assigns, jointly and severally, firmly by these present. Regardless of the number of years or license
periods this bond remains in effect, the number of premiums paid or the number of claims made, the total aggregate liability of the surety shall
not exceed the penal sum of the bond.
PROVIDED, HOWEVER, THAT THE CONDITION OF THE ABOVE OBLIGATION IS SUCH, that if the above bounded Principal shall
truly account for and pay over to the person or corporation entitled to receive the same, all money belonging to such person or corporation
which may, during the term of said license, come into the hands of said Principal as such Title Insurance Producer or the employees or agents of
Principal, including Title Insurance Producer Independent Contractors during the course of providing service for or on behalf of the Principal,
or while providing any escrow, closing, or settlement service, then this obligation shall be void, otherwise of full force and effect;
AND FURTHER PROVIDED, That the Surety may, without prejudice to any liability accrued, prior to such cancellation, cancel such bond
upon thirty (30) days’ written notice filed with the Insurance Commissioner of the State of Maryland and a copy thereof mailed to the Principal.
Signed, sealed and dated this day of , 20 .
As Witness:
By: By: (L.S.)
Witness Principal
Test as to Surety and Its Corporate Seal
By: By:
Witness Attorney-in-Fact
NOTICE TO SURETY COMPANIES AND PRINCIPAL: Be sure a concurrently dated Power of Attorney is attached to this bond,
and all signatures are affixed.
Page 7 of 8
BENEFICIARY:
MARYLAND INSURANCE ADMINISTRATION TITLE LETTER OF CREDIT
PRODUCER:
MARYLAND INSURANCE ADMINISTRATION (NAME)
ADDRESS:
IRREVOCABLE LETTER of CREDIT NUMBER:
AMOUNT: $
ISSUE DATE:
EXPIRATION:
We hereby establish our Irrevocable Letter of Credit Number
in your favor for the account of
in the amount of $150,000 available upon presentation of your draft(s) at sight drawn on the
(bank name) located at , and accompanied by:
1. A letter executed by an authorized official of the Maryland Insurance Administration stating that
(producer name)
has failed to perform his obligation while acting as a Title insurance producer or while providing any escrow, closing or settlement
services and has caused any person to suffer a loss covered by the Insurance Laws of Maryland and that such failure entitles the State of
Maryland, Maryland Insurance Administration, to draw on Irrevocable Letter of Credit Number .
2. Original of this Irrevocable Letter of Credit:
We engage with you that draft(s) drawn under and in accordance with the terms of this Letter of Credit shall be duly honored upon
presentation and delivery of documents as specified above if drawn and negotiated on or before the expiration date indicated above.
Draft(s) must be marked “Drawn on” (bank name)
Irrevocable Letter of Credit Number
It is a condition of the Letter of Credit that it shall be deemed automatically extended without amendment for one (1) year from the
present or any future expiration date unless thirty (30) days prior to such expiration date you are notified by certified mail that we elect
not to consider this Letter of Credit renewed for any such additional period.
Except as expressly stated herein, this undertaking is not subject to any condition or qualification. The
obligation of (bank name) under this Letter of Credit shall be the individual obligation
of (bank name) in no way contingent upon reimbursement with respect thereto.
Except so far as otherwise stated, this Irrevocable Letter of Credit is subject to the “Uniform Customs and Practice for Documentary
Credit” (2007 Revision), International Chamber of Commerce publication number 400.
By:
(Bank Name)
Rev. 1/2017
(Authorized Signature) (Title)
Page 8 of 8
Rev. 10/2017
DISCLOSURE AND AUTHORIZATION CONCERNING BACKGROUND REPORTS
This Disclosure and Authorization is provided to you in connection with pending or future application(s) of
[insert firm name] (“Firm”) for licensure with the Maryland Insurance Administration. Firm desires to procure a consumer
or investigative consumer report (or both)(“Background Reports”) regarding your background for review by the Maryland
Insurance Administration during the term of your functioning as, or seeking to function as, an officer, member of the board
of directors or other management representative (“Affiant”) of Firm or of any business entities affiliated with Firm (“Term
of Affiliation”) for which a Background Report is required by the Maryland Insurance Administration. Background Reports
requested pursuant to your authorization below may contain information bearing on your character, general reputation,
personal characteristics, mode of living and credit standing. The purpose of such Background Reports will be to evaluate the
Application and your background as it pertains thereto. To the extent required by law, the Background Reports procured
under this Disclosure and Authorization will be maintained as confidential.
You may obtain copies of any Background Reports about you from the consumer reporting agency (“CRA”) that produces
them. You may also request more information about the nature and scope of such reports by submitting a written request to
Firm. To obtain contact information regarding CRA or to submit a written request for more information, contact
[insert firm’s designated person, position, or department, address and phone].
Attached for your information is a “Summary of Your Rights Under the Fair Credit Reporting Act.”
AUTHORIZATION: I am currently an Affiant of Firm as defined above. I have read and understand the above
Disclosure and by my signature below, I consent to the release of Background Reports to the Maryland Insurance
Administration, and to the Firm, for purposes of investigating and reviewing such Application and my status as an Affiant. I
authorize all third parties who are asked to provide information concerning me to cooperate fully by providing the requested
information to CRA retained by Company for purposes of the foregoing Background Reports, except records that have been
erased or expunged in accordance with law.
I understand that I may revoke this Authorization at any time by delivering a written revocation to Firm and that Firm will,
in that event, forward such revocation promptly to any CRA that either prepared or is preparing Background Reports under
this Disclosure and Authorization. This Authorization shall remain in full force and effect until the earlier of (i) the
expiration of the Term of Affiliation, (ii) written revocation as described above, or (iii) twelve (12) months following the
date of my signature below.
A true copy of this Disclosure and Authorization shall be valid and have the same force and effect as the signed original.
(Printed Full Name and Residence Address)
(Signature) (Date)
Dated and signed this day of 20 at I hereby certify under penalty of
perjury that I am acting on my own behalf and that the foregoing statements are true and correct to the best of my
knowledge and belief.
(Signature of Affiant)
State of County of
The foregoing instrument was acknowledged before me this day of , 20 By
, and:
who is personally known to me, or
who produced the following identification:
[SEAL] Notary Public
Printed Notary Name
My Commission Expires