California Code of Regulations › Title 10 - Investment › Chapter 5 - Insurance Commissioner › Subchapter 3 - Insurers › Article 12.9 - Life Settlements › Section 2548.25 - Business Entity Endorsement Form

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
State of California
Department of Insurance
Business Entity Endorsement
LIC 411-8A (Rev 04/2014)
___________________________
Producer Licensing Bureau
P.O. Box 1139
Sacramento, CA 95812-1139
(916) 322-3555 or (800) 967-9331
www.insurance.ca.gov
Pursuant to Section
					 1627 and
					 1661 of the
					 Insurance Code
License Number of Business Entity:
					 ____________________
Business Entity Name:
Mailing Address:
City, State, Zip:
To the Insurance Commissioner of the State of
					 California: Effective from the date of filing this notice, the Business Entity
					 hereby endorses the person(s) named to exercise the agency or brokerage powers
					 of the business entity.
Note
: Enter only
one
endorsement type per line. (Exception
					 SL/SP)
*
AH
- Accident and
					 Health Agent *
LO
- Life-Only Agent
LI
- Life-Limited to the Payment of
					 Funeral & Burial Expenses
FX
- Fire/Casualty
					 Broker-Agent
AU
- Limited Lines
					 Automobile Insurance Agent
LA
- Life and
					 Disability Analyst
CS
- Cargo Shipper's
					 Agent **
CI
- Credit Insurance Agent
PL
- Personal Lines Broker Agent
MC
- Motor Club Agent
SL
- Surplus Line
					 Broker
SP
- Special Lines' Surplus Line
					 Broker
SL/SP
- Surplus Line & Special
					 Lines' Surplus Line Broker ***
LS
- Life
					 Settlement Broker
Endorsement Type**
Endorsee's Social
							 Security Number****
Endorsee's Name (as shown on
							 license)
Effective Date of Endorsement
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Signature
and title of authorized
					 representative.
-
Title:
Date:
E-mail:
Phone Number: ( )
Filing fee
:
Submit
					 $26 filing fee per endorsement type. Enter number of endorsements: __________ X
					 $26 __________
Please Note: If you are endorsing an applicant for an
					 insurance license, submit only one name per form and attach the form to the
					 application.
1.
If you are submitting only an
							 endorsement:
California Department of Insurance
Mail Endorsement form and fee to
							 -
P.O. Box 957
or
Sacramento, CA 95812-0957
2.
If endorsement is being submitted with
							 original application
California Department of Insurance
Mail Endorsement form with
							 application and fee to -
P.O. Box 1139
Sacramento, CA 95812-1139
* If endorsing both Accident and Health Agent and Life-Only
					 Agent submit only one filing fee.
** For Credit Insurance applicants only: submit $34 per
					 endorsement.
***There is no fee for the Life Settlement Broker.
****Disclosure of your U. S. social security number is
					 mandatory pursuant to Cal. Civil Code, §
										1798.17; Cal.
					 Family Code, §
										17520(d);
					 and Federal Privacy Act of 1974, §§
										7(a) (2) (B) and
					 7(b). Your 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.
1. New
					 section filed 7-29-2010 as an emergency; operative 7-29-2010. Emergency
					 regulation shall remain in effect, not to be repealed by the Office of
					 Administrative Law, unless repealed by the Department of Insurance pursuant to
					 Insurance Code section
					 10113.35
					 (Register 2010, No. 31).
2. Change without regulatory effect
					 amending NOTE filed 1-24-2012 pursuant to section
					 100, title 1, California Code of
					 Regulations (Register 2012, No. 4).
3. Change without regulatory
					 effect amending form and NOTE filed 7-3-2013 pursuant to section
					 100, title 1, California Code of
					 Regulations (Register 2013, No. 27).
4. Change without regulatory
					 effect amending form filed 8-14-2014 pursuant to section
					 100, title 1, California Code of
					 Regulations (Register 2014, No. 33).
5. Renumbering of former
					 section 2548.25 to section
					 2548.26 and renumbering of former
					 section 2548.24 to new section
					 2548.25 filed 11-25-2014;
					 operative 1-1-2015 (Register 2014, No. 48).
Note: Authority cited: Sections
						10113.35
						and
						12978,
						Insurance Code; CalFarm Ins. Co. v. Deukmejian, 48 Cal.3d 805 (1989); 20th
						Century Ins. Co. v. Garamendi, 8 Cal.4th 216 (1994). Reference: Sections
						10113.1 and
						10113.2,
						Insurance Code.