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
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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): _______________________________________
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