California Code of Regulations › Title 10 - Investment › Chapter 5 - Insurance Commissioner › Subchapter 1 - Production of Insurance › Article 12.5 - Travel Insurance Agent Licensing Regulations › Section 2194.25 - Application Content and Required Forms

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) The following forms shall be submitted to
				  the Department at the time of the filing of the initial application for a
				  limited lines travel insurance agent license:
(1) A written application for licensure that
				  shall include the following information concerning the applicant:
a. Business entity type (e.g., corporation,
				  LLC, general partnership, etc.)
b.
				  License type applied for.
c. Name
				  of the business entity applicant.
d. Federal employer identification
				  number.
e. Business address,
				  mailing address, telephone number.
f. Fictitious business names the applicant
				  has used or intends to use if approved by the Department.
g. Any business activity or activities that
				  the business entity applicant is engaged in, other than insurance, including
				  the nature of any such business activity or activities and the percentage of
				  the business entity applicant's net income derived from the activity or
				  activities.
h. Whether the business
				  entity applicant is an insurer.
i.
				  Whether the business entity applicant holds or has ever held an insurance
				  license, including the type of license, license number, state issuing the
				  license and dates of licensure.
j.
				  Identity of all designated / responsible license producers, including name,
				  social security number, and insurance license number. Disclosure of your U. S.
				  social security number is mandatory pursuant to Insurance Code section
				  1666.5,
				  Cal. Civil Code, §
												1798.17; Cal.
				  Family Code, §
												17520(d);
				  and Federal Privacy Act of 1974, §§
												7(a)(2)(B) and
				  7(b). The social
				  security number will be used primarily for purposes of processing your
				  application, including conducting any necessary investigation into your
				  background. If you fail to disclose your social security number, your
				  application will not be reviewed. An individual has a right of access to
				  certain records containing personal information pertaining to that individual.
				  Individuals may obtain information regarding the location of their records by
				  contacting the Bureau Chief, Producer Licensing Bureau, California Department
				  of Insurance by phone (800-967-9331) or by mail, to the following address: 320
				  Capitol Mall, Sacramento CA 95814-4309.
k. Identity of all partners, members
				  officers, directors, managers, controlling persons and any shareholders owning
				  10% or more interest in the business entity applicant, including name, title,
				  social security number, federal employer identification number, and percentage
				  of ownership.
l. Identify of each
				  controlling person as defined in California Insurance Code Section
				  1668.5(b),
				  including name, title, social security number, federal tax identification
				  number, and percentage of ownership.
m. Whether the business entity applicant or
				  any of its partners, members, controlling person, officers, directors,
				  managers, or any shareholder holding 10 percent or interest in the applicant
				  have been convicted or are currently charged with committing a crime. "Crime"
				  includes a felony, a misdemeanor or military offense. "Convicted" includes, but
				  is not limited to, having been found guilty by a verdict of a judge or jury,
				  having entered a plea of nolo contendere, no contest, having had any charge
				  expunged, dismissed or plea withdrawn pursuant to Penal Code Section
				  1203.4, or
				  having been given probation, a suspended sentence or a fine. Additionally,
				  those applicants disclosing convictions, must provide a written statement with
				  original signature explaining the circumstances of each incident as well as a
				  certified copy of the charging document and a certified copy of the official
				  document which demonstrates the resolution of the charges or any final
				  judgment.
n. Whether the business
				  entity applicant or any of its partners, members, controlling persons,
				  officers, directors, managers or any shareholders owning 10% or more interest
				  in the business entity, ever been involved in an administrative proceeding
				  regarding any professional or occupational license.
"Involved" means having a license censured, suspended,
					 revoked, canceled, terminated or, being assessed a fine, placed on probation 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. "Involved" also
					 means having a license application denied or the act of withdrawing an
					 application to avoid a denial. Additionally, those applicants disclosing
					 involvement in administrative proceedings must provide a signed, written
					 statement explaining the circumstances of each incident leading to such
					 proceeding as well as certified copies of the charging document and of the
					 official document describing the resolution of the proceeding.
o. Whether any demand has been made or
				  judgment rendered against the business entity applicant or any of its partners,
				  members, controlling persons, officers, directors, managers or any shareholders
				  owning 10% or more interest in the business entity for overdue monies by an
				  insurer, insured or producer, and whether the applicant has ever been subject
				  to a bankruptcy proceeding. Additionally, those applicants disclosing such a
				  demand or judgment must submit a statement summarizing the details of the
				  indebtedness and arrangements for repayment.
p. Whether the business entity applicant or
				  any of its partners, members, controlling persons, officers, directors,
				  managers or any shareholders owning 10% or more interest in the business
				  entity, have ever been notified by any jurisdiction of any delinquent tax
				  obligation that is not the subject of a repayment agreement. Additionally,
				  those applicants disclosing delinquent tax obligations must identify the
				  jurisdiction in which the tax obligation is delinquent.
q. Whether the business entity applicant or
				  any of its partners, members, controlling persons, officers, directors,
				  managers or any shareholders owning 10% or more interest in the business
				  entity, have ever been 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.
				  Additionally, those applicants disclosing such lawsuits and or arbitration
				  proceedings must provide a signed, written statement detailing each incident
				  and a copy of both the pleading initiating the lawsuit or arbitration as well
				  as the official document describing the final resolution of such
				  proceeding(s).
r. Whether the
				  business entity applicant or any of its partners, members, controlling persons,
				  officers, directors, managers or any shareholders owning 10% or more interest
				  in the business entity, have ever had an insurance agency contract or any other
				  business relationship with an insurance company terminated for any alleged
				  misconduct. Additionally, those applicants disclosing such terminations must
				  provide a signed, written statement describing the each underlying incident and
				  an explanation of why the incident(s) should not result in denial of the
				  license application. The applicant will also be required to provide copies of
				  all relevant documents relating to said termination(s).
s. Business entity applicant's certification
				  under penalty of perjury that:
i. The named
				  business entity intends actively and in good faith to carry on an insurance
				  business with the general public;
ii. The business entity's articles of
				  incorporation or articles of organization or association or partnership
				  agreement, as the case may be, do not forbid it to act in the capacity for
				  which this application is being made;
iii. The holding of the license hereby
				  applied for is not incompatible with the laws, rules or regulations of any
				  federal, state, county or municipal government for which it performs work (if
				  any) by which it is licensed (if any);
iv. If the license is granted, only those
				  natural persons so authorized will transact insurance under each
				  license;
v. The certification must
				  be signed by:
1. If the applicant is a
				  partnership, each partner.
2. If
				  the applicant is a corporation, an officer having authority to bind the
				  organization.
3. If the applicant
				  is a limited liability company, an officer, member or manager having authority
				  to bind the organization.
4. If the
				  applicant is a nonprofit corporation or unincorporated association, all
				  members.