| License
Type Requested: |
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If Other, please state:
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| Line
of Insurance: |
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| If
Other, please state: |
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Agency Name: |
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| Street
Address: |
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City: |
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| State:
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| Zip:
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Mailing Address:(if different from above) |
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| City:
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| State: |
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Zip: |
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Telephone#: |
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| Website:
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| Fax
#: |
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| Email:
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| Federal
ID #: |
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| Type
of Agency |
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| If
other, please state: |
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| If
Partnership, name(s) of Principals |
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| Name(s)
of Individual(s) to be licensed for the agency |
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If Agent, please provide us with the name, address and telephone #
of the contact person for the insurance company that you will represent
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| Name
of Company |
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| Address: |
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| Name
of Person to Contact: |
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| Has
the agency now in the last 5 years engaged in any business other than
the insurance business? |
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| If
yes, what business and when: |
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| What
percentage of the agency business will be spent in the insurance business: |
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| Has
the agency ever transacted business in another name? |
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| If
yes, what name: |
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| Has
the agency or any of its members ever been denied an insurance license? |
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| Is
there now pending in any state any action against the agency arising out
of its activities in the business of insurance? |
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| Has
the agency or any of its members ever been convicted of a crime (exclude
minor traffic violations) |
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| Is
the agency financially indebted to any other agency or company? |
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| Has
the agency or any of its members ever declared bankruptcy? |
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| Is
the agency associate with any lending institutions? |
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| If
yes, give name of lending institution and nature of association: |
Name of Company:
Nature of Association:
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Corporations
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| Date
Incorporated: |
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| State
Incorporated: |
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| Fiscal
Year End |
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| Fictitious
Name: |
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| Stock: |
Authorized Shares:
Issued Shares:
Per Value:
Class of Shares:
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Officers; Board
Members and Directors
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| Name: |
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| Address:
(please include street, city, state, and zip code) |
|
| Title |
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| Name: |
|
| Address:
(please include street, city, state, and zip code) |
|
| Title |
|
| Name: |
|
| Address:
(please include street, city, state, and zip code) |
|
| Title |
|
| Name: |
|
| Address:
(please include street, city, state, and zip code) |
|
| Title |
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Stockholders
and percentage of ownership
|
| Name: |
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| Address:
(please include street, city, state, and zip code) |
|
| Title |
|
| Name: |
|
| Address:
(please include street, city, state, and zip code) |
|
| Title |
|
| Name: |
|
| Address:
(please include street, city, state, and zip code) |
|
| Title |
|
| Name: |
|
| Address:
(please include street, city, state, and zip code) |
|
| Title |
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