California Code of Regulations › Title 10 - Investment › Chapter 5 - Insurance Commissioner › Subchapter 1 - Production of Insurance › Article 13 - Form of Application for Title Marketing Representative Certificate of Registration › Section 2194.55 - Prescribed Form of Application

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) In order to complete the online
				  application, the applicant shall provide the following information:
(1) Application type. The "application type"
				  of the application to be completed by an applicant for a title marketing
				  representative certificate of registration is "certificate."
(2) License type. The license type that must
				  be selected in order to apply for a title marketing representative certificate
				  of registration is Title Marketing Representative.
(3) Full legal name.
(4) Residence, business, mailing and email
				  addresses. The business and mailing addresses specified by the applicant are
				  matters of public record and shall be available to the public.
(5) Gender.
(6) Social security number.
(7) Date of birth.
(8) Country of citizenship. In addition to
				  completing the online application, an applicant indicating on the online
				  application that he or she is not a citizen of the United States must submit to
				  the Department's Producer Licensing Bureau a copy of his or her authorization
				  to work in the United States.
(9)
				  Employment history for the previous five years. The applicant must enter the
				  name of each employer, the month and year employment began, the month and year
				  employment ended, and the position held for all employment experiences starting
				  with their current employer and continuing in reverse chronological order
				  through the date that is five years before the date the online application is
				  being completed. The applicant must include any and all full-time employment,
				  part-time employment, self-employment, military service, periods of
				  unemployment, and periods during which the applicant was a full-time
				  student.
(10) Past licensing
				  history. The applicant must account for all current and past insurance licenses
				  he or she has held as a resident or as a non-resident in California or in any
				  other state. For each such license, the applicant must indicate the license
				  type, the state or province that issued the license, the period of time during
				  which the license was or has been held, and whether or not the license is
				  currently in force.
(11) Background
				  information. The applicant must answer "yes" or "no" to the following
				  background questions on the online application:
(A) Have you ever been convicted of a felony?
1. The online application will advise the
				  applicant as follows: "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."
2. If the answer to the above background
				  question is "Yes," the applicant, in addition to completing the online
				  application, must submit to the Department's Producer Licensing Bureau:
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.
An applicant who is required to submit any such certified
					 copy but who does not have it at his or her disposal must retain for his or her
					 records copies of the correspondence the applicant sends to the court or other
					 source of documents in order to obtain the required certified copy. Failure to
					 provide to the Department either copies of this correspondence, or the required
					 certified copies of the charging documents and court documents, upon the
					 Department's request shall result in the applicant's application being deemed
					 incomplete and the suspension of the applicant's authority to operate as a
					 representative on a provisional basis. The online application will advise the
					 applicant of the requirement that, unless and until the required certified
					 copies of the charging documents and court documents are in his or her
					 possession, the applicant must retain copies of this correspondence and that
					 the applicant may lose his or her provisional authority if he or she fails to
					 furnish such copies upon request.
(B) Have you ever been convicted of a felony
				  involving dishonesty or breach of trust?
1.
a. The online application will advise the
				  applicant as follows: 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 from conducting the business of
				  insurance unless they have obtained the written consent of the Insurance
				  Commissioner. It is a violation of this statute to conduct business of
				  insurance without the Commissioner's written consent. If you have been
				  convicted of a felony involving dishonesty or a breach of trust or a violation
				  of 18 U.S.C.
				  1033, 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.
b. If the answer
				  to the above background question is "Yes," the applicant must further answer
				  "yes" or "no" to the following question: "Have you received consent from the
				  Insurance Commissioner?"
2.
a. The
				  online application will advise the applicant as follows: "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."
b. If the answer to the question "Have you
				  ever been convicted of a felony involving dishonesty or breach of trust?" is
				  "Yes," the applicant, in addition to completing the online application, must
				  submit to the Department's Producer Licensing Bureau:
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.
An applicant who is required to submit any such certified
					 copy but who does not have it at his or her disposal must retain for his or her
					 records copies of the correspondence the applicant sends to the court or other
					 source of documents in order to obtain the required certified copy. Failure to
					 provide to the Department either copies of this correspondence, or the required
					 certified copies of the charging documents and court documents, upon the
					 Department's request shall result in the applicant's application being deemed
					 incomplete and the suspension of the applicant's authority to operate as a
					 representative on a provisional basis. The online application will advise the
					 applicant of the requirement that, unless and until the required certified
					 copies of the charging documents and court documents are in his or her
					 possession, the applicant must retain copies of this correspondence and that
					 the applicant may lose his or her provisional authority if he or she fails to
					 furnish such copies upon
					 request.
(C) Have you ever been convicted of a
				  misdemeanor?
1. The online application will
				  advise the applicant as follows: "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."
2. If the answer to the above background
				  question is "Yes," the applicant, in addition to completing the online
				  application, must submit to the Department's Producer Licensing Bureau:
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.
An applicant who is required to submit any such certified
					 copy but who does not have it at his or her disposal must retain for his or her
					 records copies of the correspondence the applicant sends to the court or other
					 source of documents in order to obtain the required certified copy. Failure to
					 provide to the Department either copies of this correspondence, or the required
					 certified copies of the charging documents and court documents, upon the
					 Department's request shall result in the applicant's application being deemed
					 incomplete and the suspension of the applicant's authority to operate as a
					 representative on a provisional basis. The online application will advise the
					 applicant of the requirement that, unless and until the required certified
					 copies of the charging documents and court documents are in his or her
					 possession, the applicant must retain copies of this correspondence and that
					 the applicant may lose his or her provisional authority if he or she fails to
					 furnish such copies upon request.
(D) Have you ever been convicted of a
				  military offense?
1. The online application
				  will advise the applicant as follows: "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."
2. If the answer to the above background
				  question is "Yes," the applicant, in addition to completing the online
				  application, must submit to the Department's Producer Licensing Bureau:
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.
An applicant who is required to submit any such certified
					 copy but who does not have it at his or her disposal must retain for his or her
					 records copies of the correspondence the applicant sends to the court or other
					 source of documents in order to obtain the required certified copy. Failure to
					 provide to the Department either copies of this correspondence, or the required
					 certified copies of the charging documents and court documents, upon the
					 Department's request shall result in the applicant's application being deemed
					 incomplete and the suspension of the applicant's authority to operate as a
					 representative on a provisional basis. The online application will advise the
					 applicant of the requirement that, unless and until the required certified
					 copies of the charging documents and court documents are in his or her
					 possession, the applicant must retain copies of this correspondence and that
					 the applicant may lose his or her provisional authority if he or she fails to
					 furnish such copies upon request.
(E) Are you currently charged with committing
				  a crime?
1. The online application will
				  advise the applicant as follows: " 'Crime' includes a felony, a misdemeanor or
				  a military offense. You may exclude traffic citations but must include driving
				  offenses such as, but not limited to, reckless driving, driving under the
				  influence and driving with a suspended license."
2. If the answer to the above background
				  question is "Yes," the applicant, in addition to completing the online
				  application, must submit to the Department's Producer Licensing Bureau:
a. a written statement, with original
				  signature, explaining the circumstances of each charge; and
b. certified copies of the charging
				  documents.
An applicant who is required to submit any such certified
					 copy but who does not have it at his or her disposal must retain for his or her
					 records copies of the correspondence the applicant sends to the court or other
					 source of documents in order to obtain the required certified copy. Failure to
					 provide to the Department either copies of this correspondence, or the required
					 certified copies of the charging documents, upon the Department's request shall
					 result in the applicant's application being deemed incomplete and the
					 suspension of the applicant's authority to operate as a representative on a
					 provisional basis. The online application will advise the applicant of the
					 requirement that, unless and until the required certified copies of the
					 charging documents are in his or her possession, the applicant must retain
					 copies of this correspondence and that the applicant may lose his or her
					 provisional authority if he or she fails to furnish such copies upon
					 request.
(F) Have you ever been involved in an
				  administrative proceeding (including matters with the Department of Insurance)
				  regarding any professional or occupational license?
1. The online application will advise the
				  applicant as follows: " 'Involved' means having a license censured, suspended,
				  revoked, cancelled, terminated; 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 terminations due solely to noncompliance with
				  continuing education requirements or failure to pay a renewal fee."
2. If the answer to the above background
				  question is "Yes," the applicant, in addition to completing the online
				  application, must submit to the Department's Producer Licensing Bureau:
a. a written statement, with original
				  signature, explaining the circumstances of each disciplinary incident;
				  and
b. certified copies of the
				  Notices of Hearing or other documents that state the charges and allegations,
				  and of the documents which demonstrate the resolution of the charges or any
				  final judgment.
An applicant who is required to submit any such certified
					 copy but who does not have it at his or her disposal must retain for his or her
					 records copies of the correspondence the applicant sends to the court or other
					 source of documents in order to obtain the required certified copy. Failure to
					 provide to the Department either copies of this correspondence, or the required
					 certified copies of the Notices of Hearing and other documents, upon the
					 Department's request shall result in the applicant's application being deemed
					 incomplete and the suspension of the applicant's authority to operate as a
					 representative on a provisional basis. The online application will advise the
					 applicant of the requirement that, unless and until the required certified
					 copies of the Notices of Hearing and other documents are in his or her
					 possession, the applicant must retain copies of this correspondence and that
					 the applicant may lose his or her provisional authority if he or she fails to
					 furnish such copies upon request.
(G) Has any business in which you 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?
1. The
				  online application will advise the applicant as follows: " 'Involved' means
				  having a license censured, suspended, revoked, cancelled, terminated; 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
				  terminations due solely to noncompliance with continuing education requirements
				  or failure to pay a renewal fee."
2. If the answer to the above background
				  question is "Yes," the applicant, in addition to completing the online
				  application, must submit to the Department's Producer Licensing Bureau:
a. a written statement, with original
				  signature, explaining the circumstances of each disciplinary incident;
				  and
b. certified copies of the
				  Notices of Hearing or other documents that state the charges and allegations,
				  and of any documents which demonstrate the resolution of the charges or any
				  final judgment.
An applicant who is required to submit any such certified
					 copy but who does not have it at his or her disposal must retain for his or her
					 records copies of the correspondence the applicant sends to the court or other
					 source of documents in order to obtain the required certified copy. Failure to
					 provide to the Department either copies of this correspondence, or the required
					 certified copies of the Notices of Hearing or other documents, upon the
					 Department's request shall result in the applicant's application being deemed
					 incomplete and the suspension of the applicant's authority to operate as a
					 representative on a provisional basis. The online application will advise the
					 applicant of the requirement that, unless and until the required certified
					 copies of the Notices of Hearing or other documents are in his or her
					 possession, the applicant must retain copies of this correspondence and that
					 the applicant may lose his or her provisional authority if he or she fails to
					 furnish such copies upon request.
(H) Has any demand been made or judgment
				  rendered against you for any overdue monies by an insurer, insured, or
				  producer, or have you ever been subject to a bankruptcy proceeding?
1. The online application will advise the
				  applicant as follows: "Include only bankruptcies that involve funds held on
				  behalf of others."
2. If the answer
				  to the above background question is "Yes," the applicant, in addition to
				  completing the online application, must submit to the Department's Producer
				  Licensing Bureau a statement, with an original signature, summarizing the
				  details of the indebtedness and arrangements for repayment, and/or type and
				  location of bankruptcy.
(I) Have you ever been notified by any
				  jurisdiction of any delinquent tax obligation that is not the subject of a
				  repayment agreement?
If the answer to the above question is "Yes," the applicant
					 must identify all such jurisdictions on the online
					 application.
(J) 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?
1. If the answer to the above question is
				  "Yes," the applicant, in addition to completing the online application, must
				  for each such lawsuit or proceeding submit to the Department's Producer
				  Licensing Bureau:
a. a written statement, with
				  original signature, summarizing the details of the incident;
b. a copy of the Petition, Complaint, or
				  other document that commenced the lawsuit or arbitration; and
c. a copy of any official document which
				  demonstrates the resolution of the charges or any final
				  judgment.
2. An applicant
				  who is required to submit a copy of any document required pursuant to subitem
				  (a)(11)(J)1.b. or (a)(11)(J)1.c. above but who does not have such a copy at his
				  or her disposal must retain for his or her records copies of the correspondence
				  the applicant sends to the court or other source of documents in order to
				  obtain the copy of the document that is required pursuant to subitem
				  (a)(11)(J)1.b. or (a)(11)(J)1.c. Failure to provide to the Department either
				  copies of this correspondence, or the copies of the documents that are required
				  pursuant to subitem (a)(11)(J)1.b. or (a)(11)(J)1.c, upon the Department's
				  request shall result in the applicant's application being deemed incomplete and
				  the suspension of the applicant's authority to operate as a representative on a
				  provisional basis. The online application will advise the applicant of the
				  requirement that, unless and until the copies of the documents that are
				  required pursuant to subitem (a)(11)(J)1.b. or (a)(11)(J)1.c are in his or her
				  possession, the applicant must retain copies of this correspondence and that
				  the applicant may lose his or her provisional authority if he or she fails to
				  furnish such copies upon request.
(K) 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 the answer to the above question is "Yes," the
					 applicant, in addition to completing the online application, must for each such
					 termination submit to the Department's Producer Licensing Bureau:
1. a written statement, with original
				  signature, summarizing the details of the incident and explaining why the
				  applicant feels this incident should not prevent him or her from receiving a
				  title marketing representative certificate of registration; and,
2. copies of any relevant
				  documents.
(12)
				  Applicant's certification. The applicant must certify the under penalty of
				  perjury that the applicant had read the online application, that the applicant
				  knows the contents of the information he or she has provided on the online
				  application, and that each statement made on the online application is full,
				  true and correct. The required certification includes language indicating that
				  the applicant understands that pursuant to section
				  1738, and subdivision (h) of
				  section
				  1668, of
				  the Insurance Code, any false statement made on the application or any document
				  filed in support thereof may subject the applicant's application to denial and
				  may subject the applicant's certificate to suspension or
				  revocation.